Answer for BIR CoW 23 May 2021
Hemangioma
Findings
Well defined lobulated and elongated T2 hyperintense lesion noted involving the right sartorius muscle measuring 2.4 (anteroposterior) X 2.2 (transverse) X 2.4(craniocaudal) cm Few areas blooming foci noted within the lesion on gradient images - reflecting phleboliths. Suggestive of low flow vascular malformation – Possibly Hemangioma
Discussion
Soft-tissue hemangiomas can arise from various anatomic locations, including striated muscle, skin, subcutaneous tissue, and synovial tissue, depending on the histologic subtype. A soft-tissue hemangioma may cause osseous overgrowth secondary to chronic hyperemia, depending on its location.
X-ray findings : Phleboliths are associated with cavernous hemangiomas in approximately 50% of cases . Nonspecific soft-tissue mass In large masses, osseous changes including periosteal reaction and cortical thickening can occur. Rarely , pressure erosion from the adjacent mass can result in a pathologic fracture.
US findings : Heterogenous complex mass. If phleboliths are abundant, acoustic shadowing may also be documented . Doppler evaluation may show low-resistance arterial flow with forward flow during both systole and diastole
CT findings : Ill-defined mass of similar attenuation to muscle may be identified. Phleboliths too small to identify on radiographs can be revealed. After administration of contrast material, significant enhancement is typical
MR findings : Currently, the standard for imaging evaluation of soft-tissue hemangiomas is MR imaging . Typically, all sequences show a heterogeneous mass (although lesions measuring under 2 cm tend to be homogeneous), reflecting the mix of tissues present. T1-weighted images best reveal areas of high-signal-intensity adipose tissue, most prominent along the circumference of the vascular complex. This fatty tissue may reflect muscle atrophy secondary to chronic vascular insufficiency caused by the steal phenomenon. The central angiomatous core of the neoplasm shows high signal intensity on T2-weighted images. As on contrast-enhanced CT images, the serpentine nature of the hemangioma may be depicted. If blood flow through these vascular channels is rapid enough, the signal may remain low in intensity with all MR imaging sequences. If gadolinium contrast material is administered, prominent enhancement of the angiomatous tumor is expected
REFERENCES
1 . Murphey MD, Fairbairn KJ, Parman LM, Kirkman GB, Parsa MB, Smith WS. Musculoskeletal angiomatous lesions: radiologic-pathologic correlation. RadioGraphics 1995; 15:893-917. Link, Google Scholar 2 . Greenspan A, McGahan JP, Vogelsang P, Szabo RM. Imaging strategies in the evaluation of soft-tissue hemangiomas of the extremities: correlation of the findings of plain radiography, angiography, CT, MRI, and ultrasonography in 12 histologically proven cases. Skeletal Radiol 1992; 21:11-18. Medline, Google Scholar 3 . Resnick D. Vascular and lymphatic tumors. In: Draud LA, Fix CF, eds. Diagnosis of bone and joint disorders. 4th ed. Philadelphia, Pa: Saunders, 2002; 4186-4195. Google Scholar 4 . Wild AT, Raab P, Krauspe R. Hemangioma of skeletal muscle. Arch Orthop Trauma Surg 2000; 120:139-143. Crossref, Medline, Google Scholar 5 . Paltiel HJ, Burrows PE, Kosakewich HP, Zurakowski D, Mulliken JB. Soft-tissue vascular anomalies: utility of US for diagnosis. Radiology 2000; 214:747-754. Link, Google Scholar
Findings
Well defined lobulated and elongated T2 hyperintense lesion noted involving the right sartorius muscle measuring 2.4 (anteroposterior) X 2.2 (transverse) X 2.4(craniocaudal) cm Few areas blooming foci noted within the lesion on gradient images - reflecting phleboliths. Suggestive of low flow vascular malformation – Possibly Hemangioma
Discussion
Soft-tissue hemangiomas can arise from various anatomic locations, including striated muscle, skin, subcutaneous tissue, and synovial tissue, depending on the histologic subtype. A soft-tissue hemangioma may cause osseous overgrowth secondary to chronic hyperemia, depending on its location.
X-ray findings : Phleboliths are associated with cavernous hemangiomas in approximately 50% of cases . Nonspecific soft-tissue mass In large masses, osseous changes including periosteal reaction and cortical thickening can occur. Rarely , pressure erosion from the adjacent mass can result in a pathologic fracture.
US findings : Heterogenous complex mass. If phleboliths are abundant, acoustic shadowing may also be documented . Doppler evaluation may show low-resistance arterial flow with forward flow during both systole and diastole
CT findings : Ill-defined mass of similar attenuation to muscle may be identified. Phleboliths too small to identify on radiographs can be revealed. After administration of contrast material, significant enhancement is typical
MR findings : Currently, the standard for imaging evaluation of soft-tissue hemangiomas is MR imaging . Typically, all sequences show a heterogeneous mass (although lesions measuring under 2 cm tend to be homogeneous), reflecting the mix of tissues present. T1-weighted images best reveal areas of high-signal-intensity adipose tissue, most prominent along the circumference of the vascular complex. This fatty tissue may reflect muscle atrophy secondary to chronic vascular insufficiency caused by the steal phenomenon. The central angiomatous core of the neoplasm shows high signal intensity on T2-weighted images. As on contrast-enhanced CT images, the serpentine nature of the hemangioma may be depicted. If blood flow through these vascular channels is rapid enough, the signal may remain low in intensity with all MR imaging sequences. If gadolinium contrast material is administered, prominent enhancement of the angiomatous tumor is expected
REFERENCES
1 . Murphey MD, Fairbairn KJ, Parman LM, Kirkman GB, Parsa MB, Smith WS. Musculoskeletal angiomatous lesions: radiologic-pathologic correlation. RadioGraphics 1995; 15:893-917. Link, Google Scholar 2 . Greenspan A, McGahan JP, Vogelsang P, Szabo RM. Imaging strategies in the evaluation of soft-tissue hemangiomas of the extremities: correlation of the findings of plain radiography, angiography, CT, MRI, and ultrasonography in 12 histologically proven cases. Skeletal Radiol 1992; 21:11-18. Medline, Google Scholar 3 . Resnick D. Vascular and lymphatic tumors. In: Draud LA, Fix CF, eds. Diagnosis of bone and joint disorders. 4th ed. Philadelphia, Pa: Saunders, 2002; 4186-4195. Google Scholar 4 . Wild AT, Raab P, Krauspe R. Hemangioma of skeletal muscle. Arch Orthop Trauma Surg 2000; 120:139-143. Crossref, Medline, Google Scholar 5 . Paltiel HJ, Burrows PE, Kosakewich HP, Zurakowski D, Mulliken JB. Soft-tissue vascular anomalies: utility of US for diagnosis. Radiology 2000; 214:747-754. Link, Google Scholar
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!