Vol 15 ppt

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

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

Lipid Tumors

Superficial Lipoma

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%.

Case #1183

51 year male with superficial lipoma arm

Coronal T-1 MRI

Another coronal T-1 MRI

tumor

Axial T-1 MRI

tumor

Surgical specimen

Photomic

Case #1183.1

71 year female with recent shoulder dislocation and history of a soft

tissue lump over back of shoulder for years

Superficial lipoma

Axial T-1 Gad

Case #1183.2 Superficial lipoma

Axial T-1 PD FS

42 yr male with one yr history of painless lump on shoulder

Intramuscular

Lipomas

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.

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%.

CLASSIC

Case #270

72 year male with an

intramuscular lipoma

quadriceps muscle

Coronal T-1 MRI

Another coronal T-1 MRI

Axial T-1 MRI

Gross specimen

Photomic

Case #270.1

Axial T-1 T-1 STIR

72 year female with painless mass in anterior thigh for years

Intramuscular lipoma

Coronal T-1 Sagittal T-1 Coronal STIR

Case #270.2 Axial T-1 T-2

Gad

56 year male with painless soft

mass in anterior thigh for 2 years

Sag T-1 T-2 FS

Case #270.3

65 year old female with

3 yr history of large painless

mass in posterior thigh

Intraneural lipoma sciatic nerve

Sag T-1 T-2

Axial T-1 PD

Surgical resection

Case #271

74 year female with intramuscular lipoma hand

Coronal T-1 MRI

Axial T-1 MRI

Surgical resection

Photomic

Case #272

47 year female with intramuscular lipoma foot

Sagittal T-1 MRI

Axial T-1 MRI

Coronal T-1 MRI

Case #273

11 year male

lipoma

deltoid muscle

Axial T-1 MRI

Coronal T-1 MRI

Case #273.1

43 year female with soft painless mass in axilla

Axial T-1

T-2

Sag T-1 T-2

Cor T-1

Case #274

67 year male

calcifying necrotic

lipoma

Resected specimen cut in path lab

calcification

Case #1184

58 year female with


buttock area

Axial T-1 MRI showing lipoma extruding thru the sciatic notch

Coronal T-1 MRI showing lipoma extrusion thru the notch

Surgical specimen

Case #1184.1

51 year old male with soft painless mass in buttocks for 5 yrs

CT scan Lipoma

Axial T-1 T-2

Gad

Cor T-1 T-2

Gad

Sag gad

Case #1185

59 year female with


anterior proximal thigh

Coronal T-1 MRI

Axial T-2 MRI

Axial T-2 MRI

at lower level

Fat subtraction MRI

showing signal void

in lipoma

Case #1186

51 year male with


posterior compartment

thigh

Axial T-1 MRI

Case #1187

62 year female with


adductor compartment

thigh

Coronal T-1 MRI

Surgical exposure of tumor

Case #1188

72 year female with


mid arm

Axial T-1 MRI

Case #1189

2 year male with


posterior thigh

AP view

Case #1190

66 year female with intramuscular lipoma forearm

CT scan

tumor

Case #1190.1

55 year female with painless mass in forearm over 1 yr

Intramuscular lipoma

Sagittal MRI

T-1 T-1 PD-FS Gad

Axial T-1

Gad

Surgical resection

Case #1190.2


painless lump at ankle

for 1 year

Sag T-1 PD Gad

Axial T-1 Gad

Surgical excision

Spindle Cell

Lipomas

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.

CLASSIC Case #275

59 year male with spindle cell lipoma thigh

CT scan

Case #276

64 year male with spindle cell lipoma proximal forearm

Sagittal T-1 MRI

Axial T-1 MRI

Axial proton density MRI

Angiolipomas

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.

CLASSIC Case #277

27 year female with angiolipoma forearm showing

phleboliths and hypertrophic subadjacent radius

phleboliths

Sagittal T-1 MRI showing low signal serpinginous

vessels running thru high signal lipoma tissue

Resection specimen showing serpinginous vessels in fat

Case #278 Coronal T-1 MRI

16 year female with angiolipoma quadriceps muscle

Axial T-1 MRI

Case #1191

24 year female with

angiolipoma anterior

thigh

Sagittal T-1 MRI

Axial T-1 MRI

Coronal T-2 MRI

Sagittal gad

contrast MRI

Case #1192

23 year female with

angiolipoma anterior

to hip joint

Axial T-1 MRI

Sagittal T-1 MRI

Coronal T-1 MRI

Case #1194

41 year male with

angiolipoma thigh

Coronal T-1 MRI

Axial T-1 MRI

Case #1194.1

33 year female with painless mass in anterior thigh 1 year

Axial T-1 MRI

Axial T-2

Axial Gad Contrast

Sagittal T-2 Sagittal Gad

Case #1195

17 year female with

angiolipoma forearm

Sagittal T-1 MRI

Coronal T-1 MRI

Axial T-2 MRI

Case #1196

33 year male with

angiolipoma calf

Axial T-1 MRI

Sagittal T-1 MRI

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.

Case #1196.1

75 yr female with painless soft mass in thigh for 10 yrs

Ossifying Lipoma

Axial T-1

Sag T-1 Axial T-2

bone

Necrotic tumor

fat

Surgical removal of the

large mass from the

quadriceps muscle

Photomics show typical

lipoma tissue covering

necrotic ossifying tissue

Post op appearance following resection

Case #1196.2 Ossifying Lipoma

53 yr male with painless

mass in knee for 3 yrs

Cor T-1 Axial T-2

Case #1196.3

60 yr female with painless forearm mass for 2 years

Ossifying lipoma

Sag T-1 T-2 FS Gad

Axial T-1 T-2 FS

Gad

Myxolipoma

CLASSIC Case #279 Sagittal T-1 MRI

63 year female with myxolipoma knee

Sagittal T-2 MRI

Axial T-1 MRI

Diffuse

Lipomatosis

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.

CLASSIC Case #280

20 year male with diffuse lipomatosis lower extremities

CT scan

Another CT cut

Lumbosacral

Lipoma

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.

CLASSIC

Case #281

Sagittal T-1 MRI

lumbosacral lipoma

61 year male

Axial T-1 MRI

Synovial Lipoma

Case #281.1

26 year male with injury to shoulder 6 years ago

Synovial lipoma

Axial T-1

Axial T-2

Cor T-1

Cor T-2

Sag T-2

Case #281.2 Synovial lipoma knee Axial

T-1 T-2

Gad


tender lump over medial

retinaculum for l year

Coronal T-1 T-2 Gad

Sagittal T-1 T-2 Gad C+

Hibernoma

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.

Case #1197

CLASSIC

37 year female with

hibernoma triceps m

Sagittal T-1 MRI

Axial T-1 MRI

Axial T-2 MRI

Axial gad

contrast MRI

Sagittal gad contrast

MRI

Surgical specimen showing tan color

Photomic

Case #1197.1

38 year female with painless hibernoma anterior thigh

Sag T-1 MRI Cor T-1 MRI Axial T-1 MRI

Sagittal T-2 MRI Sagittal Gad MRI

Case #1197.2

28 yr male with fullness in groin area for 1 yr

hibernoma

Axial T-1 PD

Gad

Sag PD Sag Gad

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

Coronal T-1 MRI Coronal T-2 MRI

Sagittal T-1 MRI Sagittal T-2 MRI

Liposarcoma

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.

Well-differentiated

Liposarcoma

(Atypical Lipoma)

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.

CLASSIC

Case #283

Coronal T-1 MRI

63 year female

Well-differentiated

liposarcoma thigh

Resected surgical specimen

Case #283.1 Well Differentiated Liposarcoma Thigh

68 yr old male with three time recurrence of soft mass in thigh

Cor T-1 STIR Gad

Axial T-1 STIR

Gad

Case #284

Coronal T-1 MRI

49 year male with

well-differentiated

liposarcoma (atypical lipoma)

distal thigh

Sagittal T-1 MRI

Axial T-2 MRI

Case #1198

62 year male with well-differentiated liposarcoma thigh

Axial T-2 MRI

Coronal T-2 MRI

Case #1198.1

Sag T-1 PD

47 yr old female with mild intermittent pain in thigh 2 yrs

Atypical Lipoma

Axial T-1 PD

Gad

Case #1198.2

Coronal T-1 MRI of

the thigh of a 41 year

male with prior history

of partially resected

atypical lipoma 3 yrs

before

Dedifferentiated lipsosarcoma

Axial PD Axial Gad

Sagittal Gad

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

Sag T-1 Gad

09

Axial T-1 upper T-2 upper

T-2 lower Cor STIR

Surgical removal

Case #1198.4 Sag T-1 T-2 FS Gad

45 yr female with atypical lipoma resected from calf 3 yrs ago

Axial T-1 Gad

Tumor resection off the posterior tibial nerve

nerve

Myxoid

Liposarcoma

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

liposarcomas occurring in the extremities as well as in retroperitoneal 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.


67 year female with myxoid liposarcoma knee

Sagittal T-2 MRI

Axial T-2 MRI

Resection specimen

Photomic showing lipoblasts and vascular channels

Case #286 Sagittal T-2 MRI

43 year male with myxoid liposarcoma behind knee

tumor

Coronal T-2 MRI

tumor

Axial T-1 MRI

tumor

Surgical resection

Cut specimen

Photomic

vessel

lipoblasts

Case #287

Coronal T-1 MRI

29 year male with

myxoid liposarcoma

posterior thigh

tumor

Axial PD MRI

tumor

Axial T-2 MRI

Wide resection specimen

Photomic showing numerous vascular channels


34 year female with myxoid liposarcoma thigh

Coronal T-2 MRI

Axial T-1 MRI

tumor

Axial T-2 MRI

tumor

Photomic

Axial T-2 MRI showing multifocal involvement in abdomen

tumor

kidney

Case #289

Sagittal T-1 MRI

32 year male with

myxoid liposarcoma

distal thigh

tumor

Axial T-1 MRI

tumor

Resected specimen

Specimen cut in path lab

fat

myxoid

Photomic

Case #1199

30 year male with

myxoid liposarcoma

posterior thigh

Sagittal T-1 MRI

Sagittal T-2 MRI

Axial T-1 MRI

tumor

Axial Gad contrast MRI

Coronal Gad

contrast MRI

Surgical specimen

Photomic

Case #1200 Sagittal T-1 MRI

75 year male with myxoid liposarcoma foot

Another sagittal T-1 MRI

Axial T-1 MRI

tumor

Sagittal T-2 MRI

Another sagittal T-2 MRI

Sagittal Gad contrast MRI

Photomic showing lipoblasts

Case #1201

69 year male with myxoid liposarc pelvis

tumor

CT scan

Axial T-2 MRI

Photomic showing lipoblasts and vessels

Case #1201.1

27 year male with

myxoid liposarcoma

vastus intermedius m.

Axial T-1 MRI

Coronal T-1 MRI

Coronal Gad

contrast MRI

showing femoral

artery

Surgical incision including biopsy site

Surgical exposure of tumor contained in muscle fascia

biopsy

Tumor excised including periosteum

Excised tumor mass contained in muscle fascia

biopsy site

Wound closure

Case #1201.2 Axial T-1 STIR

Gad 70 yr female with slightly

tender mass above elbow

for 1 year

Myxoid Liposarcoma Triceps

Sag T-1 STIR Gad

Ulnar N

Surgical resection

Round Cell

Liposarcoma

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.

CLASSIC

Case #290

38 year male with

high grade round cell

liposarcoma thigh

Sagittal T-1 MRI

tumor

Sagittal T-2 MRI

tumor


tumor

Photomic showing round cells and lipoblasts

Pleomorphic

Liposarcoma


44 year male with pleomorphic liposarcoma knee

tumor

Sagittal T-1 MRI

tumor

Axial gad contrast MRI

tumor

Photomic showing bizarre pleomorphic giant cells

Close up of pleomorphic lipoblasts

Case #1202

80 year male with

pleomorphic liposarcoma

Sagittal T-1 MRI

Sagittal T-2 MRI

Surgical specimen

Photomic

Case #1203

61 year male with

pleomorphic liposarcoma

biceps muscle

Sagittal T-1 MRI

Sagittal T-2 MRI

Case #1203.1

65 year male with recent onset buttock tumor mass in area of previous

resected large benign lipoma 6 years ago

Axial CT scan Pleomorphic liposarcoma

Sag CT scan Cor CT

Axial T-1 T-2

Gad

fluid

tumor

Sag T-2 Surgical specimen

Vascular Tumors

Hemangioma

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

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

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.

CLASSIC

Case #292

14 year female

hemangioma foot

AP x-ray showing

phleboliths

Lateral x-ray showing more phleboliths

Axial T-1 MRI

tumor

Axial T-2 MRI

tumor

Gross specimen with hemorrhagic cysts

Photomic

Case #293

36 year female

hemangioma hand

X-ray showing calcifying mass

AP and oblique views

Surgical removal

Photomic showing cavernous vascular spaces

Case #293.1

57 year female with

tender mass under

volar aspect of 3rd

MP joint for years

Hemagioma of hand

Axial T-1 prox phalanges T-2

Gad PD metacarpal heads

Cor T-1 T-2

Gad

Case #293.2


tender lump beneath 2nd

MP joint for years

Hemagioma hand

Cor T-1 T-2 FS

Gad

Axial T-1 T-2 FS

Gad

Gad

47 year old male with long

history intermittent painful

swelling palm of hand

Case #293.3 Tenosynovial Hemangioma Hand

Cor T-1 T-2

Axial T-1

Gad

Case #294

30 year female with hemangioma hand

Case #295

8 year female with

hemangioma distal arm

phlebolith

Lateral view

Coronal T-1 MRI Coronal T-2 MRI

Sagittal T-1 MRI Sagittal T-2 MRI

Axial T-1 MRI Axial T-2 MRI

Photomic showing large vascular spaces

bone

Case #295.1 Recurrent hemangioma

24 year female with recurrent hemangioma triceps

phleboliths

Coronal T-1 T-2

Sagittal T-1 T-2

Axial

T-1

T-2

Gad

Case #295.2

16 year female with tender mass in posterior arm for years

Cor CT Axial CT

Hemagioma triceps m

Cor T-1 T-2 Gad

Axial PD Gad

Sag PD Gad

Case #296

24 year female with hemangioma forearm with phleboliths

Case #297

6 year female

hemangioma forearm

phlebolith

Case #297.1

18 year old female with forearm mass for years

Cor T-1 Gad

Hemangioma forearm

Axial T-1

Axial Gad

Case #297.2

46 yr male with

tender soft mass

forearm for years

Hemangioma forearm

Cor T-1 T-2 Gad

Sag T-1 T-2 Gad

Axial T-1 T-2

Gad

Case #298

10 year female with a

hemangioma distal

leg and foot

Sagittal T-2 MRI

Axial T-2 MRI

Sagittal T-1 MRI foot

Sagittal T-2 MRI

Axial T-2 MRI

Case #298.1 Hemangioma Ankle Sag Gad

52 yr female with 30 year history of intermittent pain in ankle

Cor T-1 T-2 FS Gad

Axial T-1 T-2 FS

Gad

Surgical resection

Case #298.1

15 year male with tender

mass lateral side of forefoot

for many years

Hemangioma

Axial T-1

T-2

Sag T-1

T-2

Cor T-2

Case #1204

22 year male with

hemangioma anterior

compartment leg with

subadjacent cortical

hypertrophy of tibia

Axial gad

contrast MRI

Coronal T-1 MRI

Case #1204.1

31 year female with soft swelling in leg for many years

Cor Ct

Axial CT

Cor T-2 Sag Gad Sag Gad

Axial Gad Axial Gad

Case #1205

38 year female with

hemangioma forearm

with hypertrophic response

in subadjacent ulna

Bone scan

Axial PD MRI

bone hypertrophy

Axial gad contrast MRI

Sagittal T-2 MRI

Case #1206

31 year female with

hemangioma leg with

hypertrophic response

in adjacent fibula

Axial T-2 MRI

Coronal T-1 MRI

Case #1207

25 year female with hemangioma buttock area

tumor calcification

Coronal T-1 MRI

Sagittal T-2 MRI

Case #1207.1

65 year old female

with tender lump in

buttock for 1 year

Axial T-1 T-2

Gad

Hemangioma

buttock

Cor T-2

Sag T-2

CT scan

Pet scan

Case #1208

28 year female with hemangioma gastroc muscle

tumor calcification

Sagittal T-1 MRI

Axial T-1 MRI

Case #1208.1

Axial CT scan Sag

43 year old female with tender lump in medial gastroc for years

Axial T-2 Gad

Sag T-1 Gad

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

Axial T-1 T-2

Gad

Case #1209

17 year male with

hemangioma in

quadriceps muscle

Axial T-2 MRI

Case #1210

14 year female with

hemangioma hind foot

Axial T-2 MRI

Case #1211

67 year female with

synovial hemangioma

hip joint with secondary

erosion of femoral

head and neck

Synovial biopsy showing numerous vascular spaces

4 year male with painless mass below the patella 1 yr

Case #1211.1 Synovial hemangioma knee

Sagittal T-1 Sagittal T-2

Axial T-1 Axial T-2 Axial Gad

Case #1211.2

15 year male with knee pain for 6 months

Synovial hemagioma knee

Coronal T-1 Coronal T-2

Axial T-2

Surgical exposure at time of excisional biopsy

Case #1211.3

68 year old female with soft mass medial knee for years

Synovial hemangioma knee

Cor T-1 T-2

Gad

Sag PD Gad

Axial T-2 Gad

Hemangiomatosis

CLASSIC

Case #299

Stillborn with extensive

hemangiomatosis

Upper body showing disappearing bones

Lower half of body

Lower extremity with

disappearing bones

in hemangiomatosis

Case #300

25 year female

hemangiomatosis

upper extremity with

disappearing bones

phleboliths

Case #1212

34 year female with hemagiomatosis forearm

phleboliths

Case #1212.1

39 year male with extensive hemangiomatosis thigh

Coronal T-1

MRI

arteriogram

Lymphangiomas

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.

CLASSIC

Case #301

23 year female

lymphangioma forearm

and hand with

thumb gigantism

Surgical specimen from forearm

Photomic showing lymphatic channels

Case #302

7 month male

lymphangioma

elbow

Coronal T-1 MRI

Axial T-2 MRI

Case #303

10 year female with lymphangioma forearm


fluid cyst

Axial T-2 MRI

Case #304 Axial T-1 MRI

21 year female with lymphangioma inguinal area

Axial T-1 MRI more distal

Axial T-1 MRI even more distal

Surgical specimen cut in path lab

Photomic with lymphatic channels

Case #304.1

Gad

8 yr old male with soft mass

over buttock for years with

intermittent clear serous fluid

drainage

Cor T-1 T-2

Lymphangioma Buttock

Axial T-1 Axial T-2

Axial Gad Sag T-2

Case #1213

46 year male with

lymphangioma arm

Axial PD MRI

Another T-2 MRI

showing 2 lesions

Coronal T-2 MRI

showing lymphangioma

next to cephalic vein

vein

Sagittal T-2 MRI

showing hygroma

next to brachial

vessels

vessels

Photomic of lymphangioma

Glomus Tumor

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.

CLASSIC Case #305

50 year male with glomus tumor thumb

AP x-ray

Surgical removal

Photomic showing hemangiopericytes

blood

Case #306

45 year female with glomus tumor web space hand

Case #307

Surgical exposue subcutaneous glomus tumor

forearm 45 year female

Hemangiopericytoma

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.


87 year female with hemangiopericytoma below groin

Another sagittal

T-1 MRI

Cut specimen in path lab

Photomic


45 year male with hemangiopericytoma thigh

Axial T-1 MRI

Axial T-2 MRI

tumor

Case #310 Axial T-1 MRI

44 year female with hemgiopericytoma thigh

Axial T-2 MRI

tumor

Sagittal T-2 MRI

tumor

Case #311

58 year female

malignant hemangiopericytoma

arm

Coronal T-1 MRI

tumor

Coronal proton density MRI

tumor

Axial proton

density MRI

tumor

Kaposi’s Sarcoma

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.

Case #312

75 year female with Kaposi’s sarcoma foot

Plantar view

Cut resected specimen

Photomic

Case #313

65 year male with Kaposi’s sarcoma foot

Photomic

Angiosarcoma

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.

CLASSIC Case #314 Sagittal proton density MRI

30 year male with high grade angiosarcoma heel

Coronal T-2 MRI

Sagittal proton density MRI

Metastasis to inguinal lymph node

Sagittal T-2 MRI of positive lymph node

Low power photomic

Higher power showing pleomorphic giant cells

around vascular spaces

Case #314.1

52 yr old male with

tender mass in proximal

anterior thigh area 3 mos

Angiosarcoma Thigh

Axial T-1 STIR

Cor STIR Sag STIR

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