Volume 17


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Volume 17

  1. 1. Volume 17Chondroid tumors Synovial chondromatosis---------Case 364-370 & 1243-5 Juxtaarticular chondroma---------Case 371-377 & 1246-7 2ndary synovial chondromatosis-Case 378-382 & 1248 Myxoid chondrosarcoma----------Case 383-385Epithelioid sarcoma------------------Case 386-389Soft tissue Ewing’s sarcoma--------Case 390-392Clear cell sarcoma--------------------Case 393-394Myositis ossificans-------------------Case 395-405Pigmented villonodular synovitis---Case 406-416 & 1249Intramuscular myxoma---------------Case 1258Ganglion cyst--------------------------Case 1259-60Soft tissue lympoma------------------Case 1261
  2. 2. Chondroid Tumors
  3. 3. SynovialChondromatosis
  4. 4. Synovial Chondromatosis Synovial chondromatosis is a rare dysplasia seen in youngerpatients. It is associated with metaplastic cartilage within thesynovial lining of major joints such as the hip, knee, shoulder andelbow. It is twice as common in males as females and usuallyoccurs in patients in the 20-40 age group. It is a monarticulardisease that presents with symptoms of crepitation in the affectedjoint with mild, intermittent effusion sometimes associated withpain. Because of chronic irritation to the joint and damage to thearticular cartilage, osteoarthritis is an ultimate problem with thisdisease and can lead to a total joint replacement at a later age. Inrare instances this condition can mutate into a secondary chondro-sarcoma, usually around the hip or knee joint but seldom in theshoulder area. This usually occurs in the later years of life. In the early stages before the cartilage becomes calcified, thesynovial chondromatosis may be difficult to pick up on routineradiographic examination. As time passes, the cartilage begins
  5. 5. to calcify in a typical chondroid pattern that suggests the diagnosisof a chondroid tumor in or about a major joint. With excessiveproliferation, the cartilage can extrude out of the joint into adjacentsoft tissue, similar to what occurs with pigmented villonodularsynovitis. As the disease progresses, it is not unusual to seeenchondral ossification occurring within the cartilage when it isstill attached to the synovial lining and has access to a blood supply.Multiple loose bodies are common with this disease and can run ashigh as 200 pellets within a major joint that sometimes aggregrateinto a large mass that has the appearance of a chondrosarcoma. Treatment consists of a surgical resection of the loose bodies aswell as a subtotal synovectomy of the tissue that produces the loosebodies. Multiple surgical procedures may be required because of ahigh recurrence rate. As in PVNS, it is not unusual to see a solitaryfocus of synovial chondromatosis with the remaining synoviallining being normal in appearance with only a solitary mass ofcartilage attached to the synovial lining. This localized nodular form
  6. 6. is more common about the hip, knee and ankle area. It is verycommon to find loose bodies in a major arthritic joint in olderpatients secondary to osteoarthritis where the joint cartilage isbroken away from the joint surface and than becomes reattachedto the synovial lining and gives the pseudo-appearance of primarysynovial chondromatosis when, in fact, the primary etiology inthis so-called secondary form is degenerative osteoarthritis. Thesecondary form is seen in patients past the age of 50 years, where-as the primary dysplastic form arising from the synovial liningis seen during the first three to four decades of life.
  7. 7. CLASSIC Case #36433 year male with synovial chondromatoasis of shoulder
  8. 8. Sagittal T-2 MRI showing multiple calcified cartilage bodies
  9. 9. Coronal T-2 MRIshowing loose bodies
  10. 10. Surgical exposure showing loose bodies
  11. 11. Loose bodies and synovial lining following surgery
  12. 12. Cartilaginous bodies arising from synovial lining
  13. 13. Cartilaginous body formation in synovial villus
  14. 14. Case #36526 year male withsynovial chondromatosisknee joint
  15. 15. AP x-ray
  16. 16. Gross appearance of synovial chondromatosis
  17. 17. Microscopic evidence of cartilage elements in synovium
  18. 18. Case #366 28 year female with synovial chondromatosis knee
  19. 19. Another view
  20. 20. Photomic showing cartilage in synovial lining
  21. 21. Case #366.163 year female with long history of synovial chondromatosis
  22. 22. Sag T-2Sag Gad
  23. 23. Cor T-2 Axial Gad
  24. 24. Case #366.2 Synovial chondromatosis 42 year female with grinding sensations in knee for years
  25. 25. Case #367 38 year male with synovial chondromatosis left hip
  26. 26. Frog leg lateral
  27. 27. Coronal T-2 MRI
  28. 28. Sagittal T-2 MRI cutshowing loose bodies
  29. 29. Surgical removal of cartilage bodies
  30. 30. Photo of largest cartilage body
  31. 31. Case #368 24 year female with large cartilaginous pelvic mass arising from synovial chondromatosis of left hip
  32. 32. tumorClose up of deformed femoral neck
  33. 33. tumor Note deformity of medial femoral neck
  34. 34. femoral NExposure of large pelvic tumor by removal ant pubic ramus
  35. 35. pubic grooveResected cartilage masses and loose hip joint bodies
  36. 36. Cut specimen of one mass formed from compressed pellets
  37. 37. Loose bodies from hip joint
  38. 38. cartilagePhotomic of cartilage forming in synovial lining
  39. 39. Post op x-ray showing ramus surgical defect
  40. 40. 9 years later with DOA requiring THA
  41. 41. Case #36959 year male withsynovial chondromatosisright hip for 20 years
  42. 42. 5 years later with 2ndarychondrosarcoma infemoral neck
  43. 43. Frog leg lateral showing chondrosarcoma
  44. 44. Femoral head & neck specimen from THA showing chondrosarcoma in lower neck area
  45. 45. chondrosarcomaSynovectomy specimen obtained at time if THA
  46. 46. Photomic of chondrosarcoma
  47. 47. 1 yr later we see recurrent tumor requiring hemipelvectomy
  48. 48. Case #37050 year female with25 year history ofsynovial chondromatosis
  49. 49. Coronal T-2 MRI several years later with 2ndary chondrosarc
  50. 50. DedifferentiatedCase #370.1 Cor T-1 T-2 chondrosarcoma60 yr male with swollen knee for years with recent increase in size
  51. 51. Cor T-2 Gad
  52. 52. Sag T-2 Gad T-2
  53. 53. Axial T-2Gad
  54. 54. Case #124320 year female withsynovial chondromatosiship
  55. 55. Frog leg lateral
  56. 56. CT scan showing loose bodies
  57. 57. Case #124426 year female withsynovial chondromatosiship
  58. 58. CT scan
  59. 59. CT scan at lower level
  60. 60. Photomic showing embryonic cartilage in synovial lining
  61. 61. Case #1245 49 year female with synovial chondromatosis wrist
  62. 62. AP view
  63. 63. Axial Gad contrast MRI
  64. 64. loose pellets fluidSagittal T-1 MRI showing wrist effusion and loose pellets
  65. 65. Juxta-articular Chondroma
  66. 66. CLASSIC Case #37125 year old with juxta-articular chondroma posterior knee
  67. 67. AP view
  68. 68. Surgical excision
  69. 69. Surgical specimen
  70. 70. X-ray of resectedspecimen
  71. 71. Photomic
  72. 72. Case #372 41 year male with juxta-articular chondroma ant knee
  73. 73. Sagittal T-1 MRI
  74. 74. Sagittal T-2 MRI
  75. 75. Axial T-2 MRI
  76. 76. Photomic
  77. 77. Case #372.1 Juxtr-articular chondroma 60 yr female with lump in anterior knee area for years
  78. 78. Sag T-1 T-2 Gad
  79. 79. Axial T-1 PDGad
  80. 80. Case #37358 year male with juxta-articular chondroma posterior knee
  81. 81. Sagittal T-2 MRI
  82. 82. Axial T-2 MRI
  83. 83. Case #374 Sagittal T-1 MRI tumor 37 year male with juxta-articular chondroma post knee
  84. 84. Sagittal T-2 MRI
  85. 85. tumorSagittal gad contrast MRI with rim enhancement
  86. 86. tumorAxial T-2 MRI
  87. 87. tumorAxial gad contrast with rim enhancement
  88. 88. Case #1248 36 year male with soft tissue chondrosarc behind knee
  89. 89. Sagittal T-2 MRI
  90. 90. Axial T-1 MRI
  91. 91. Axial T-2 MRI
  92. 92. Case #37513 year male with juxta-articular chondroma posterior knee
  93. 93. Case #376 18 year male with juxta-articular chondroma ankle
  94. 94. Case #376.1 Juxta-articular chondroma 38 old male with long history of catching sensations in ankle
  95. 95. Axial T-1 PD Gad
  96. 96. Sag T-1 PD Gad
  97. 97. Case #377 19 year male with tenosynovial chondromatosis
  98. 98. Lateral view
  99. 99. Photomic
  100. 100. Case #124744 year male withsolitary synovialchondroma hip
  101. 101. Lateral view
  102. 102. Photomic from resected specimen
  103. 103. Secondary SynovialChondromatosis
  104. 104. CLASSICCase #37849 year female with2ndary synovialchondromatosis fromosteoarthritis of kneeAP x-ray
  105. 105. Lateral view
  106. 106. Sagittal T-2 MRI
  107. 107. Axial protondensity MRI fluid
  108. 108. Axial T-2 MRI
  109. 109. Case 379 Coronal T-1 MRI osteoarthritis 76 year male with 2ndary synovial chondromatosis knee
  110. 110. Sagittal T-2 MRIshowing loosebodies in poplitealsynovial cyst
  111. 111. Axial T-2 MRI with loose body in popliteal cyst
  112. 112. Axial T-2 MRI with many loose bodies in popliteal cyst
  113. 113. Case #379.1 Secondary synovial chondromatosis 57 year old soccer player with prior history of knee surgery
  114. 114. Sag T-1 T-2 Gad
  115. 115. Axial T-2 Gad
  116. 116. Case #38070 year female2ndary synovialchondromatosis fromosteoarthritis knee
  117. 117. Lateral view
  118. 118. Case #38155 year female2ndary synovialchondromatosis fromosteoarthritis knee
  119. 119. Lateral view
  120. 120. Sagittal proton density MRI showing loose bodies in popliteal cyst
  121. 121. Case #381.1 Secondary synovial osteochondromatosis62 year old male with DOA and largenecrotizing mass over tibia
  122. 122. Sag T-1 T-2 Gad
  123. 123. T-2 Gad Axial T-2 Gad
  124. 124. Post op surgicaldebriedmentPost op flapcoverage overtibia
  125. 125. Case #38269 year male with 2ndarysynovial chondromatosisfrom traumatic arthritisof elbow
  126. 126. Surgical removal of loose bodies
  127. 127. Loose bodies and pieces of synovium
  128. 128. Case #124646 year female 2ndary synovial chondromatosis talonarvicular second to old trauma of subtalar joint
  129. 129. Sagittal T-1 MRI showing traumatic arthritic changes
  130. 130. Sagittal T-2 MRI showing excessive synovial fluid
  131. 131. Coronal T-2 MRI
  132. 132. MyxoidChondrosarcoma
  133. 133. Myxoid Chondrosarcoma (Chordoid Sarcoma) The extra-skeletal myxoid chondrosarcoma is a very rare softtissue tumor in the deep muscle belly, occurring most often in theextremities in patients over 40 years of age. Males are affectedtwice as often as females. The tumor is slow growing and maycause local pain and tenderness. Common locations are the thigh,popliteal fossa, and shoulder girdle. It presents with the clinicalappearance of a myxoid liposarcoma. Pathologically, the tumorsare greyish to tannish brown, depending on the amount ofhemorrhage into the tumor. Because hemorrhage often occurs, itcan be mistaken for a hematoma. Histologically, the tumor has amyxoid appearance with chords and nests of anastomosing cellsthat have a chondroblastic appearance. The histology is verysimilar to that of chordoma of the sacrum. The tumor is consideredlow grade in most instances; it is slow growing but has the potential
  134. 134. for local recurrence and pulmonary metastases in about one-thirdof cases. Treatment consists of aggressive wide local resection oramputation, if needed, followed by local radiation therapy. Chemo-therapy is usually not indicated.
  135. 135. CLASSIC Case #383 Coronal T-1 MRI tumor 55 year male with myxoid chondrosarcoma distal thigh
  136. 136. Coronal T-2 MRI tumor
  137. 137. tumorAxial T-2 MRI
  138. 138. Resected hemorrhagic surgical specimen
  139. 139. Photomic showing chordoid myxoid pattern like chordoma
  140. 140. Pathology similar to that of a chordoma
  141. 141. Case #384 Sagittal T-2 MRI tumor 41 year female with myxoid chondrosarcoma shoulder
  142. 142. tumorAxial gad contrast MRI
  143. 143. Case #38565 year male withsoft tissue myxoidchondrosarcoma legeroding tibiaAP view
  144. 144. Lateral view
  145. 145. Sagittal T-2 MRI tumor
  146. 146. tumorAxial T-2 MRI
  147. 147. tumorAnother axial T-2 MRI
  148. 148. Epithelioid Sarcoma
  149. 149. Epithelioid Sarcoma The epithelioid sarcoma affects young adults and is mostcommonly seen in the fingers, hand and forearm where it isconsidered the most common soft tissue sarcoma next to thealveolar rhabdomysarcoma and synovial sarcoma. It can also occurin the popliteal area, the buttock, thigh, shoulder, foot and anklearea. It affects twice as many males as females. These tumors arefrequently misdiagnosed as a benign granulomatous process andare often attached to tendon sheaths and facial planes withassociated cutaneous ulcerations that may be multiple in nature.Calcification or even bone formation can occur in about 15% ofcases. The histological appearance of this lesion displays a distinctnodular growth pattern with epithelioid nests of cells at the centersurrounded by lymphocytic infiltration. The differential diagnosiswould include necrotizing infectious diseases such as tuberculosisor granuloma annulare or rheumatoid nodules. Regional lymph
  150. 150. node involvement occurs in about 35% of cases and metastases tothe lung in about 50% of cases. Because of the benign clinicalappearance of this lesion, it is common for surgeons to attemptlocal resection but there is a high recurrence rate that eventuallyleads to amputation. Local radiation therapy can help to decreasethe chance of local recurrence.
  151. 151. CLASSIC Case #38636 year male withepithelioid sarcomafoot ulceration
  152. 152. Side view with ulcerated cap
  153. 153. tumorCT scan
  154. 154. tumorAnother CT cut
  155. 155. necrotic centerScanning lens photomic
  156. 156. Close up outer edge
  157. 157. Higher power of epithelioid cells
  158. 158. Case #38734 year male withepithelioid sarcomaforearmSagittal T-2 MRI
  159. 159. Sagittal Gad contrast MRI tumor
  160. 160. tumorAxial T-2 MRI
  161. 161. necrosis tumorAxial gad contrast MRI
  162. 162. Photomic showing epithelioid cells
  163. 163. Case #387.1 Epithelioid sarcoma 22 year old male with spontaneous fungating wound volar wrist
  164. 164. Cor T-1 T-2 FS Gad
  165. 165. Sag T-1 T-2 FS Gad
  166. 166. Axial T-1 T-2 FS Gad
  167. 167. Case #388 27 year female with epithelioid sarcoma sole of foot
  168. 168. Case #388Sagittal T-1 MRI
  169. 169. Axial proton density MRI
  170. 170. Axial T-2 MRI tumor
  171. 171. Case #389 50 year male with epithelioid sarcoma middle finger
  172. 172. Soft TissueEwing’s Sarcoma
  173. 173. Extra-skeletal Ewing’s Sarcoma Ewing’s sarcoma is usually associated with primary tumor ofbone but in a small percentage of cases, Ewing’s sarcoma canoccur in soft tissue completely unattached to the skeletal system.However, the histological appearance and the clinical pictureassociated with soft tissue Ewing’s sarcoma is basically the sameas that of skeletal Ewing’s. This condition is seen in patientsbetween the age of 15 and 30 years. It occurs in males and femalesequally and is rare in black patients. The most common locationis the chest wall, followed by the lower extremities, paraspinousarea, pelvis, hip and retroperitoneum. The least common locationis the upper extremity. The reciprocal translocation of the longarm of chromosomes 11 and 22 is seen in soft tissue Ewing’s,just as it is in skeletal Ewing’s. The prognosis for five year survivalis approximately 65%, similar to that of skeletal Ewing’s. Treatmentconsists of wide local resection when possible, followed by
  174. 174. local radiation therapy if indicated. Adjuvant chemotherapy iscommonly used because of the excellent response, similar tothat of skeletal Ewing’s sarcoma.
  175. 175. CLASSIC Case #39028 year female withsoft tissue Ewing’ssarcoma anterior thighCoronal proton densityMRI
  176. 176. Coronal protondensity MRI
  177. 177. Coronal T-2 MRI tumor
  178. 178. tumorAxial T-2 MRI
  179. 179. Surgical specimen inked and cut in path lab
  180. 180. Photomic
  181. 181. Case #390.1 Axial T-1 MRI 38 year female with painful thigh mass 2 months
  182. 182. Axial T-2Axial Gad necrosis
  183. 183. necrosisCoronal T-2 Coronal Gad contrast
  184. 184. Case #39114 year male withsoft tissue Ewing’ssarcoma distal thigh
  185. 185. Axial protondensity MRI tumor
  186. 186. Axial T-2 MRI tumor
  187. 187. Photomic
  188. 188. Case #391.1 T-1 Sag MRI T-2 Sag18 yr female with Ewing’s sarcoma in sciatic nerve looking like a benign neurilemoma
  189. 189. Axial Gad MRI at two different levelsLower level Upper level
  190. 190. Coronal Gad MRI
  191. 191. Case #39216 year female withsoft tissue Ewing’ssarcoma thigh
  192. 192. Coronal T-1 MRI
  193. 193. tumor Axial T-2 MRI
  194. 194. Clear CellSarcoma
  195. 195. Clear Cell Sarcoma The clear cell sarcoma is thought to be a deep, non-cutaneousvariant of the pigmented melanoma. It is a very rare tumor affectingfemales more than males. It is typically seen between the ages of20 and 40 years. It usually occurs in tendon sheaths and fascialplanes, especially around the foot and ankle area, similar to theclinical appearance seen with synovial sarcoma with which it canbe confused. The tumor usually begins as a slow growing lump thathas a benign appearance but after a period of several years the tumorwill start growing more rapidly and become painful. It has a highpotential to metastasize to local lymph nodes and to the lung.Approximately 50% of patients with this tumor will be dead in fiveyears. The microscopic appearance is similar to that of the epithelioidsarcoma, especially if melanin is not found in the specimen.Treatment usually consists of wide local resection, if possible, but ahigh local recurrence rate is common because of its location in
  196. 196. extracompartmental structures such as tendon sheaths. If thatoccurs, amputation is carried out for local control of the disease.Local radiation therapy is utilized with attempts at wide resection.Adjuvant chemotherapy has been advised because of the poorprognosis but the response is usually not beneficial.
  197. 197. CLASSIC Case #393 35 year female with clear cell sarcoma hand
  198. 198. Surgical exposure reveals extensive tendon sheath involvement
  199. 199. Photomic
  200. 200. Case#394 Sagittal gad contrast MRI tumor 73 year female with clear cell sarcoma ankle
  201. 201. tibia heel cord tumor Axial gad contrast MRI
  202. 202. MyositisOssificans
  203. 203. Myositis Ossificans Myositis ossificans is a heterotopic ossification within musclefascial planes seen typically in young athletic individuals in theiradolescence and early adult life. It occurs primarily in males andusually results from a significant injury to a muscle, such as atearing of the quadriceps muscle which is the most commonlocation for this problem. It is also seen in the gluteus maximusand the brachialis muscle at the elbow. The calcification is typicallynoted on x-ray three to four weeks after the injury. It tends to occurat the periphery of the damaged muscle and hematoma is usuallyseen in the central area. As the lesion matures the calcific rimaround the damaged muscle will appear as fairly mature boneand the central area will remain radiolucent, giving the so-calledzonal pattern that is almost diagnostic of traumatic myositisossificans. This is the opposite of osteosarcoma of soft tissue thathas the most dense portion of the calcifying lesion occurring centrallyand the more lytic portion at the periphery of the lesion. Myositis
  204. 204. ossificans can also be seen in older patients with no history oftrauma in which case the clinician becomes concerned about thepossibility of a neoplasm such as a synovial sarcoma or soft tissueosteosarcoma. Histologically, the lesion will have the appearanceof a healing fracture, including immature cartilage and boneformation, along with hematoma in the early stages. In rare cases,after a period of 25 or 30 years, these dormant lesions can reactivateand develop into an osteosarcoma. Treatment usually consists ofrest until the lesion matures after six months, at which point thepatient is usually asymptomatic. There is no reason to remove thelesion unless there is significant clinical disability related tostiffness of the adjacent joint. There is a hereditary congenital form of myositis ossificansreferred to as myositis ossificans progressiva, or the newer term-inology is fibrodysplasia ossificans progressiva, that is typicallyseen in children under the age of ten years. It presents with aclinical picture of progressive fibroblastic proliferation and
  205. 205. subsequent calcification and ossification of subcutaneous fat,muscles, tendons, appeneuroses, and ligaments. This condition canbe associated with symmetrical malformations of the digits withmicrodactyly of the thumbs and great toes, sometimes associatedwith a failure of segmentation of the digital bony structures. Thecondition usually presents between birth and the first six years ofage. It is inherited as an autosomal dominant trait. Males andfemales are equally affected and the calcification in soft tissues isusually precipitated by a local injury to the soft tissue. It occurstypically in the musculature of the back, shoulder, paravertebralregion and upper arms. Fusion of the tempromandibular joint canbe seen. If the respiratory muscles are affected, death can resultbecause of respiratory failure or pneumonia in early adult life. Theprognosis for survival is very poor and most patients die within thefirst ten to fifteen years of life. Biopsy or trauma of the affectedareas should be avoided because of new lesions that mightdevelop. There is no effective treatment or this condition.
  206. 206. CLASSIC Case #39512 year female withmyositis ossificansmedial thigh
  207. 207. fibrous tissueCut surgical specimen showing mature bone at periphery
  208. 208. Photomic showing reactive bone at periphery of lesion
  209. 209. Less bone maturity toward center of lesion
  210. 210. Healing rhabdomyoblasts in center of lesion
  211. 211. Case #39659 year male withearly myositisossificans ant thigh
  212. 212. Lateral view
  213. 213. Axial T-2 MRI
  214. 214. Axial T-2 MRI
  215. 215. Macro section of resected specimen
  216. 216. boneReactive bone at periphery
  217. 217. Case #397 biopsy22 year male with earlymyositis ossificansanterior thigh
  218. 218. bone fibrousBiopsy specimen with typical benign zonal pattern
  219. 219. Mature myositisossificans 6 mos later
  220. 220. Case #398 2 mos later early17 year male with myositis ossificans of thigh 2 mos apart
  221. 221. Case #39924 year femalemyositis ossificans2 months post injury
  222. 222. Axial T-1 MRI
  223. 223. Axial T-2 MRI
  224. 224. Coronal T-2 MRI
  225. 225. Biopsy specimen showing reactive bone
  226. 226. cartilage bone Close up of reactive bone and cartilage
  227. 227. Case #40014 month male withmyositis ossificansbrachialis muscle fromfall 2 weeks ago
  228. 228. Case #40114 year male withmyositis ossificanstriceps musclemature
  229. 229. Case #40210 year old female with myositis ossificans of shoulder
  230. 230. Case #403 62 year female with old myositis ossificans teres major
  231. 231. Coronal T-1 MRI
  232. 232. Superficial biopsy specimen shows benign reactive bone
  233. 233. A deeper specimen reveals OGS arising from previous myositis ossificans
  234. 234. MyositisOssificansProgressiva
  235. 235. CLASSIC Case #40422 year male withmyositis ossificansprogressiva
  236. 236. Heavy ossification oflatissimus dorsi muscle
  237. 237. X-ray showingossification oflatissimus dorsi muscle
  238. 238. Spontaneous fusioncervical spine
  239. 239. Ossification psoas m
  240. 240. Heterotopic ossification seen muscle biopsy
  241. 241. Microdactyly both great toes
  242. 242. X-ray of feet showing failure of segmentation great toes
  243. 243. Hands showing stiff thumbs and hypoplastic 5th digits
  244. 244. X-ray showing hypoplasia of 1st and 5th digits
  245. 245. Case #40526 year male withmyositis ossificansprogressiva withspontaneous fusionscoliotic spine
  246. 246. Spontaneous extra-articular fusion left hip
  247. 247. PigmentedVillonodular Synovitis
  248. 248. Pigmented Villonodular Synovitis The etiology of pigmented villonodular synovitis (PVNS)remains controversial. It presents as an inflammatory synovialdisease, usually involving only one joint, but histologically thedisease presents with histiocytic proliferation in the subsynovialtissue that takes on the characteristics of a neoplastic conditionsimilar to that of a giant cell tumor. PVNS occurs typically in thesubsynovial tissue about major joints of the lower extremity inpatients between the ages of 20 and 40 years. The knee joint is themost common site, followed next by the hip, ankle and foot. It israre to see this disease in the upper extremity. The histiocyticproliferation in subsynovial tissues is similar to that seen in giantcell tumor of tendon sheathes in the hand and foot., The clinicalpicture in the knee joint is that of spontaneous swelling associatedwith pain and synovial hypertrophy. Hemarthrosis can result inmassive swelling about the knee joint and can occasionally result
  249. 249. in juxta-articular erosion of bone, similar to what is seen inrheumatoid synovitis. Other clinical conditions with a similarpresentation include hemophilia and coccydiomycosis. In fewerthan 10 % of cases this condition will present as a localized focalmass in the suprapatellar pouch of the knee or high in the poplitealspace posteriorly that can masquerade as a neoplastic conditionsuch as a synovial sarcoma. Treatment for the more generalized synovial involvement ofthe knee joint or other lower extremity joints consists of a subtotalsynovectomy that in many cases can be performed through anarthroscope. In more extensive cases an open procedure may benecessary. The recurrence rate is fairly high, in the range of 30%.In cases where multiple recurrences result, treatment with radiationtherapy in the neighborhood of 1500-3000 centigray by externalbeam is used. Injectable isotopes have also been used for radiationtreatment of recurrent cases. Secondary arthritic changes, especiallyin the knee joint, can occur as a late complication of this disease
  250. 250. and these changes could lead to a total joint replacement at theage of 50 or 60 years. On very rare occasion, this disease canconvert to a neoplastic sarcoma with a high degree of giant cellactivity. This is similar to the conversion of a giant cell tumor toa malignant sarcoma.
  251. 251. CLASSICCase #40636 year male withPVNS knee
  252. 252. Lateral x-ray of kneeshowing soft tissueswelling
  253. 253. AP x-ray showingearly osteoarthritis
  254. 254. Sagittal T-1 MRIshowing hypertrophicsynovitis bone erosion
  255. 255. hemosiderin cyst ladenSagittal T-2 MRI erosion
  256. 256. Axial T-1 MRI showing hypertrophic synovitis
  257. 257. cystCoronal T-2 MRI
  258. 258. Brown discoloration of hypertrophic synovitis at surgery
  259. 259. Photomic showing giant cell activity
  260. 260. Photomic showing hemosiderin laden macrophages
  261. 261. Surgical appearance following subtotal synovectomy
  262. 262. Case #407 Sagittal proton density MRI 41 year female with PVNS knee
  263. 263. fluidhemosiderin laden synovitis Axial GRE T-2 MRI
  264. 264. Surgical exposure of brown hypertrophic synovitis
  265. 265. Photomic showing giant cell activity
  266. 266. Case #407.1 38 year male with intermittent pain and swelling rt knee 2 years
  267. 267. Sag T-2 T-2 Gad
  268. 268. Axial T-2 Gad
  269. 269. Case #407.2 Recurrent PVNS43 yr male with 5 scopes over 7 yrs for intermittent painful swelling about the left knee
  270. 270. Sag PD T-2 FS T-2 FS
  271. 271. Axial T-2
  272. 272. Cor T-1 T-2
  273. 273. Case #40855 year femalePVNS knee withlarge subchondrallytic granuloma
  274. 274. Coronal T-1 MRI
  275. 275. Case #40938 year male withPVNS hip joint withlarge supra-acetabulargranuloma
  276. 276. Diffuse synovialhypertrophic nodularityseen with arthrogram
  277. 277. Treatment in the 60’swith a cup arthoplastyand bone graft to theacetabular granuloma
  278. 278. Case #410 Sagittal proton density MRI 17 male with localized nodular form of PVNS
  279. 279. Sagittal T-2 MRI
  280. 280. Axial T-2 MRI
  281. 281. Surgical specimen
  282. 282. Photomic showing hemosiderin laden macrophages
  283. 283. Case #410.1 Sag T-1 PD Nodular PVNS 45 year female with knee pain for 5 months
  284. 284. Cor T-1 PD FS
  285. 285. Surgical excision
  286. 286. Case #410.2 Localized nodular form of PVNS 32 yr male with dull pain R knee for 5 months
  287. 287. Sag T-1 T-2 Gad
  288. 288. Axial T-1 T-2 Gad
  289. 289. Cor T-1 T-2 FS Gad
  290. 290. Case #411 Sagittal proton density MRI erosion50 year male with PVNS knee with large popliteal mass
  291. 291. Sagittal T-2 MRI
  292. 292. Case #412 Sagittal T-1 MRI 17 year female with PVNS ankle
  293. 293. Sagittal T-2 MRI
  294. 294. Another sagittal T-2 cut
  295. 295. Synovectomy specimen
  296. 296. Photomic
  297. 297. Case #413 Sagittal T-1 MRI 39 year female with diffuse form of GCT tendon sheath
  298. 298. Axial T-1 MRI
  299. 299. tumorAxial T-2 MRI
  300. 300. Photomic
  301. 301. Case #41467 year female withgiant cell tumor oftendon sheath
  302. 302. X-ray showing bonyerosion
  303. 303. Case #415 14 year female with GCT tendon sheath
  304. 304. X-ray showing bony erosion
  305. 305. digital nerveSurgical resection
  306. 306. Case #416 14 year female with xanthomatous variant of giant cell tumor of tendon sheath on index finger
  307. 307. Surgical resection
  308. 308. Photomic showing cholesterol laden foam cells
  309. 309. Case # 1249 20 year female with PVNS knee
  310. 310. Lateral view
  311. 311. R L Bone scan
  312. 312. Sagittal T-1 MRI
  313. 313. Coronal T-1 MRI
  314. 314. Coronal gad contrast MRI
  315. 315. Case #1250 PVNS DOA 68 year male with PVNS and DOA left knee
  316. 316. Lateral view showing subchondral erosions
  317. 317. Axial T-1 MRI with subpatellar synovial hypertrophy
  318. 318. Sagittal T-1 MRI showing extensive suprapatellar pouch involvement
  319. 319. Sagittal T-2 MRI showing fluid in suprapatellar pouch
  320. 320. Coronal T-2 MRI withdark signal hemosiderinladen synovitis andbright signal synovialfluid
  321. 321. Another coronalT-2 MRISubchondral erosions
  322. 322. Case #125134 year male withPVNS kneeSagittal T-1 MRI
  323. 323. Sagittal GRE T-2*MRI
  324. 324. Another sagittalGRE T-2* MRI
  325. 325. Coronal GRE T-2* MRI
  326. 326. Case #125223 year male with PVNSsuprapatellar pouch areaCoronal T-1 MRI
  327. 327. Coronal T-2 MRI
  328. 328. Axial T-2 MRI
  329. 329. Case #1253 Sagittal T-1 MRI 19 year male with localized nodular form of PVNS knee
  330. 330. Coronal T-1 MRI
  331. 331. Coronal T-2 MRI
  332. 332. Case #1254 40 year female with PVNS hip joint
  333. 333. CT scan
  334. 334. Axial T-1 MRI
  335. 335. Axial T-2 MRI
  336. 336. Case #125532 year male withPVNS hip joint
  337. 337. Case #125640 year female withpigmented villonodulartenosynovitis flexorhallicus longus tendonsheathSagittal T-1 MRI
  338. 338. Coronal T-1 MRI
  339. 339. Axial T-1 MRI
  340. 340. Axial T-2 MRI
  341. 341. hemosiderin histiocytesPhotomic showing giant cell activity
  342. 342. Case #1256.1 12 year old male with tender lump under heel cord 4 months
  343. 343. Sag T-1 PD Gad
  344. 344. Axial T-1 T-2Gad
  345. 345. Case #12578 year female withGCT tendon sheath2nd toe
  346. 346. Sagittal T-1 MRI
  347. 347. Coronal T-1 MRI
  348. 348. Case #1257.1 GCT tendon sheath 53 yr female with tender and swollen 2nd toe for 1 yr
  349. 349. Cor T-1 T-2 FS Gad
  350. 350. Axial T-1 T-2 FS Gad
  351. 351. Sag T-1 T-2 Gad
  352. 352. Intramuscular Myxoma
  353. 353. Case #1258 Axial T-2 Axial Gad46 yr female with painless lump in post axilla for 8 years
  354. 354. Sagittal T-2 Sagittal Gad
  355. 355. Coronal Gad Surgical specimen
  356. 356. Case #1258.1 68 year old male with painless lump right shoulder for 1 yr
  357. 357. Cor T-1 T-2
  358. 358. Sag T-1 T-2
  359. 359. Case #1258.2 Axial T-1 T-259 year male with painless softtissue mass medial calf for 6 mos. Gad Intramuscular myxoma
  360. 360. SagittalT-1 T-2 Gad
  361. 361. Ganglion Cyst
  362. 362. Case #1259 Axial T-148 yr male withpainless lump inanterior thigh 1 yr T-2
  363. 363. Axial GadShows rim enhancement Sagittal Gad
  364. 364. Case #1260 Ganglion cyst 49 year female with tender lump medial knee for 6 mos
  365. 365. Cor T-1 Cor T-2
  366. 366. Case #1160.1 Ganglion cyst 65 year female with non tender mass over patellar ligament
  367. 367. Sag T-1 PD FS
  368. 368. Cystic lateral meniscusCase #1261 Axial T-1 T-2 49 year male with prior history of subcutaneous ganglion cyst removed from knee area 6 years ago
  369. 369. Cor T-1 T-2
  370. 370. Case #1261.1 Axial T-1 T-2 Gad72 year male with painless lump lateral ankle for 1 year
  371. 371. Cor STIR Surgical excision
  372. 372. Ganglion cystCase #1261.2 Axial T-245 year male runnerWith tender nodule inMedial gastroc head Gad
  373. 373. Cor T-2 Gad
  374. 374. Case #1261.3 Ganglion cyst 60 year male with mild R hip pain for 1 year
  375. 375. Cor T-1 PD Gad
  376. 376. Axial T-2
  377. 377. Soft Tissue Lymphoma
  378. 378. Case #1262 Axial T-1 T-2 Lymphoma100 year old male with chronic edemain legs but recent tender lump in calffor 3 months Gad
  379. 379. Sag T-1 STIR Gad