Volume 15

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Volume 15

  1. 1. Volume 15 Lipid Soft Tissue TumorsSuperficial lipomas-------------Case 1183Intramuscular lipomas----------Case 270-274 & 1184-1190Spindle cell lipomas------------Case 275-276Angiolipomas--------------------Case 277-278 & 1191-1196Myxolipomas--------------------Case 279Diffuse lipomatosis-------------Case 280Lumbosacral lipoma------------Case 281Hibernoma-----------------------Case 1197Liposarcoma Well differentiated------------Case 283 & 1198 Myxoid-------------------------Case 285-289 & 1199-1201 Round cell---------------------Case 290 Pleomorphic-------------------Case 291 & 1202-1203
  2. 2. Vascular Soft Tissue TumorsHemangioma---------------------Case 292-298 & 1204-1211Hemangiomatosis---------------Case 299-300 & 1212Lymphangioma------------------Case 301-304 & 1213Glomus tumor-------------------Case 305-307Hemangiopericytoma-----------Case 308-311Kaposi’s sarcoma----------------Case 312-313Angiosarcoma--------------------Case 314
  3. 3. Lipid Tumors
  4. 4. Superficial Lipoma
  5. 5. Superficial Lipomas Lipomas are by far the most common soft tissue tumor encounteredin orthopedic oncology. There is a large number of variants, the mostcommon being the superficial subcutaneous lipoma that occurs inboth males and females in an older age group, the 5th and 6th decadeof life. Typical lesions are seen in the back, shoulder and neck. Onpalpation, these tumors have a soft non-tender characteristic. Theyoccur more commonly in obese patients, however, when patientslose weight dramatically, the size of the lipoma will not vary. Inolder patients they grow quite rapidly at first but then stop. Theynever convert into a malignant tumor at some later date. Surgicaltreatment usually consists of a cosmetic resection and the recurrencerate is less than 5%.
  6. 6. Case #1183 Coronal T-1 MRI 51 year male with superficial lipoma arm
  7. 7. Another coronal T-1 MRI tumor
  8. 8. tumor Axial T-1 MRI
  9. 9. Surgical specimen
  10. 10. Photomic
  11. 11. Case #1183.1 Superficial lipoma71 year female with recent shoulder dislocation and history of a soft tissue lump over back of shoulder for years
  12. 12. Axial T-1 Gad
  13. 13. Case #1183.2 Axial T-1 PD FS
  14. 14. Intramuscular Lipomas
  15. 15. Intramuscular Lipoma The intramuscular lipoma occurs in adults between the ages of30 and 60 years, and is usually found in the larger muscle groups.The tumor occurs quite gradually, without symptoms of pain, anddoes not cause disability when left untreated. It is usuallyrecognizable on routine radiographic exam, showing a well-marginated lesion with a radiodensity less than that of thesurrounding muscle. However, the best imaging study for a lipomaof muscle is the MRI which shows a diagnostic high signal,lobulated lesion on the T-1 weighted image that has the exactsame appearance as the subcutaneous fat. On the T-2 image, thelesion will be an intermediate signal and again have the exactappearance of subcutaneous fat. Histologically, the intramuscularlipoma demonstrates large lipocytes with very small pyknoticnuclei. The pathologist must be very careful to look for evidence ofatypical lipoblasts that would suggest the diagnosis of a well-differentiated liposarcoma that can coexist with a benign lipoma.
  16. 16. On rare occasion, lipomas can have coexistent chondroid or osseoushamartomatous elements that in the past had been classified asmesenchymomas. Surgical treatment for the intramuscular lipoma isa marginal resection, being careful to avoid damage to the neuro-vascular structures that might pass through the lipoma. Therecurrence rate is higher than for subcutaneous lipomas and rangebetween 15 and 60%.
  17. 17. CLASSICCase #27072 year male with anintramuscular lipomaquadriceps muscle
  18. 18. Coronal T-1 MRI
  19. 19. Another coronal T-1 MRI
  20. 20. Axial T-1 MRI
  21. 21. Gross specimen
  22. 22. Photomic
  23. 23. Case #270.1 Intramuscular lipomaAxial T-1 MRI T-1 STIR72 year female with painless mass in anterior thigh for years
  24. 24. Coronal T-1 Sagittal T-1 Coronal STIR
  25. 25. Case #270.2 Axial T-1 T-2 Gad 56 year male with painless soft mass in anterior thigh for 2 years
  26. 26. Sag T-1 T-2 FS
  27. 27. Case #270.3 65 year old female with 3 yr history of large painless mass in posterior thigh
  28. 28. Sag T-1 T-2
  29. 29. Axial T-1 PD
  30. 30. Surgical resection
  31. 31. Case #271 74 year female with intramuscular lipoma hand
  32. 32. Coronal T-1 MRI
  33. 33. Axial T-1 MRI
  34. 34. Surgical resection
  35. 35. Photomic
  36. 36. Case #272 Sagittal T-1 MRI 47 year female with intramuscular lipoma foot
  37. 37. Axial T-1 MRI
  38. 38. Coronal T-1 MRI
  39. 39. Case #273 Axial T-1 MRI11 year malelipomadeltoid muscle
  40. 40. Coronal T-1 MRI
  41. 41. Case #273.1 Axial T-1 T-2 43 year female with soft painless mass in axilla
  42. 42. Sag T-1 T-2Cor T-1
  43. 43. Case #27467 year malecalcifying necroticlipoma
  44. 44. calcification Resected specimen cut in path lab
  45. 45. Case #118458 year female withintramuscular lipomabuttock area
  46. 46. Axial T-1 MRI showing lipoma extruding thru the sciatic notch
  47. 47. Coronal T-1 MRI showing lipoma extrusion thru the notch
  48. 48. Surgical specimen
  49. 49. Case #1184.1 Lipoma CT scan 51 year old male with soft painless mass in buttocks for 5 yrs
  50. 50. Axial T-1 T-2 Gad
  51. 51. Cor T-1 T-2 Gad
  52. 52. Sag gad
  53. 53. Case #118559 year female withintramuscular lipomaanterior proximal thighCoronal T-1 MRI
  54. 54. Axial T-2 MRI
  55. 55. Axial T-2 MRIat lower level
  56. 56. Fat subtraction MRIshowing signal voidin lipoma
  57. 57. Case #118651 year male withintramuscular lipomaposterior compartmentthigh
  58. 58. Axial T-1 MRI
  59. 59. Case #118762 year female withintramuscular lipomaadductor compartmentthighCoronal T-1 MRI
  60. 60. Surgical exposure of tumor
  61. 61. Case #118872 year female withintramuscular lipomamid arm
  62. 62. Axial T-1 MRI
  63. 63. Case #11892 year male withintramuscular lipomaposterior thigh
  64. 64. AP view
  65. 65. Case #1190 66 year female with intramuscular lipoma forearm
  66. 66. tumorCT scan
  67. 67. Case #1190.1 Intramuscular lipoma 55 year female with painless mass in forearm over 1 yr
  68. 68. Sagittal MRIT-1 T-1 PD-FS Gad
  69. 69. Axial T-1 Gad
  70. 70. Surgical resection
  71. 71. Case #1190.2 Ossifying lipoma 60 yr female with painless forearm mass for 2 years
  72. 72. Sag T-1 T-2 FS Gad
  73. 73. Axial T-1 T-2 FS Gad
  74. 74. Case #1190.233 year old female withpainless lump at anklefor 1 year
  75. 75. Sag T-1 PD Gad
  76. 76. Axial T-1 Gad
  77. 77. Surgical excision
  78. 78. Spindle Cell Lipomas
  79. 79. Spindle Cell Lipoma The spindle cell lipoma is seen more commonly in men betweenthe ages of 45 and 65 years and is typically located in the posteriorneck or shoulder area. MRI imaging demonstrates the high signalfeatures of a lipoma on the T-1 weighted image but with areas oflower signal streaking seen throughout the high signal areas wherethe fibrous tissue is located. Histologically, the spindle cell lipomalooks 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 amarginal resection and carries a minimal chance for local recurrence.
  80. 80. CLASSIC Case #275 CT scan 59 year male with spindle cell lipoma thigh
  81. 81. Case #276 64 year male with spindle cell lipoma proximal forearm
  82. 82. Sagittal T-1 MRI
  83. 83. Axial T-1 MRI
  84. 84. Axial proton density MRI
  85. 85. Angiolipomas
  86. 86. Angiolipoma The angiolipoma is another variant of the lipoma occurring usuallyin subcutaneous locations in young adult patients. It is seen mostcommonly in the forearm. These lesions may be multiple and can bepainful because of their increased vascularity. These lesion can beseen on routine radiographs when phleboliths are present in thevascular component, but the most diagnostic imaging study is theMRI that will show the high signal features of a lipoma on the T-1weighted image with the additional serpinginous low signal patternof vascular tissue streaking throughout the high signal lipomatoustissue. Treatment for this variant is a simple marginal resectionfrom which one can expect a relatively low recurrence rate.
  87. 87. CLASSIC Case #277 phleboliths 27 year female with angiolipoma forearm showing phleboliths and hypertrophic subadjacent radius
  88. 88. Sagittal T-1 MRI showing low signal serpinginous vessels running thru high signal lipoma tissue
  89. 89. Resection specimen showing serpinginous vessels in fat
  90. 90. Case #278 Coronal T-1 MRI 16 year female with angiolipoma quadriceps muscle
  91. 91. Axial T-1 MRI
  92. 92. Case #119124 year female withangiolipoma anteriorthighSagittal T-1 MRI
  93. 93. Axial T-1 MRI
  94. 94. Coronal T-2 MRI
  95. 95. Sagittal gadcontrast MRI
  96. 96. Case #119223 year female withangiolipoma anteriorto hip joint
  97. 97. Axial T-1 MRI
  98. 98. Sagittal T-1 MRI
  99. 99. Coronal T-1 MRI
  100. 100. Case #119441 year male withangiolipoma thighCoronal T-1 MRI
  101. 101. Axial T-1 MRI
  102. 102. Case #1194.1 Axial T-1 MRI33 year female with painless mass in anterior thigh 1 year
  103. 103. Axial Gad ContrastAxial T-2
  104. 104. Sagittal T-2 Sagittal Gad
  105. 105. Case #119517 year female withangiolipoma forearmSagittal T-1 MRI
  106. 106. Coronal T-1 MRI
  107. 107. Axial T-2 MRI
  108. 108. Case #119633 year male withangiolipoma calf
  109. 109. Axial T-1 MRI
  110. 110. Sagittal T-1 MRI
  111. 111. Myxolipoma
  112. 112. CLASSIC Case #279 Sagittal T-1 MRI 63 year female with myxolipoma knee
  113. 113. Sagittal T-2 MRI
  114. 114. Axial T-1 MRI
  115. 115. DiffuseLipomatosis
  116. 116. Diffuse Lipomatosis An extremely rare variant of the lipoma is the diffuse lipomatosisform seen during the first two years of life. It may involve oneentire extremity or the trunk, demonstrating both superficial anddeep intramuscular, multifocal lesions. Histologically, these lesionsare identical to that of a benign lipoma and because of the massiveinvolvement of the extremity in some cases, amputation may beindicated.
  117. 117. CLASSIC Case #280 20 year male with diffuse lipomatosis lower extremities
  118. 118. CT scan
  119. 119. Another CT cut
  120. 120. Lumbosacral Lipoma
  121. 121. Lumbosacral Lipoma The lumbosacral lipoma variant is frequently associated with aspinabifida defect in the spine and can be seen in both the pediatricand 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 responseon the T-1 weighed image, like all other forms of lipomas. Treatmentconsists of a marginal surgical resection, including the lesions withinthe vertebral canal. A low recurrence rate is anticipated.
  122. 122. CLASSICCase #281Sagittal T-1 MRIlumbosacral lipoma61 year male
  123. 123. Axial T-1 MRI
  124. 124. Synovial Lipoma
  125. 125. Case #281.1 Synovial lipoma 26 year male with injury to shoulder 6 years ago
  126. 126. Axial T-1Axial T-2
  127. 127. Cor T-1Cor T-2
  128. 128. Sag T-2
  129. 129. 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
  130. 130. Coronal T-1 T-2 Gad
  131. 131. Sagittal T-1 T-2 Gad C+
  132. 132. Hibernoma
  133. 133. Hibernoma The hibernoma is a very rare lipoma variant seen usually in youngadults in the intrascapular area of the back. It is painless and slowgrowing and ranges between 10 and 15 cm in diameter. Histolo-logically, the hibernoma demonstrates fine granular or vaculatedcells consisting of brown fat and large amounts of glycogen. Thetreatment for this lesion is simple marginal resection with a verylow potential for local recurrence.
  134. 134. Case #1197CLASSIC37 year female withhibernoma triceps mSagittal T-1 MRI
  135. 135. Axial T-1 MRI
  136. 136. Axial T-2 MRI
  137. 137. Axial gadcontrast MRI
  138. 138. Sagittal gad contrastMRI
  139. 139. Surgical specimen showing tan color
  140. 140. Photomic
  141. 141. Photomic
  142. 142. Case #1197.1 Sag T-1 MRI Cor T-1 MRI Axial T-1 MRI 38 year female with painless hibernoma anterior thigh
  143. 143. Sagittal T-2 MRI Sagittal Gad MRI
  144. 144. Case #1197.2 hibernoma 28 yr male with fullness in groin area for 1 yr
  145. 145. T-1 Axial PD Gad
  146. 146. Sag PD Sag Gad
  147. 147. 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
  148. 148. Coronal T-1 MRI Coronal T-2 MRI
  149. 149. Sagittal T-1 MRI Sagittal T-2 MRI
  150. 150. Liposarcoma
  151. 151. Liposarcoma Second to the MFH, the liposarcoma is the most common softtissue tumor seen in the musculoskeletal system. These tumors areseen typically in an older population group (over the age of forty)and are slightly more common in males than females. They aretypically located in large muscle groups, especially in the lowerextremity where 70% of these tumors will be found. There are foursubtypes of liposarcoma, including the well-differentiated formand the myxoid form that are low grade, and the round cell andpleomorphic forms that are high grade.
  152. 152. Well-differentiated Liposarcoma
  153. 153. Well-differentiated Liposarcoma The well-differentiated liposarcoma is a very low grade variantof the liposarcoma that looks almost like a benign lipoma. It occursin people past the age of 45 years and is commonly seen in thelower extremity, especially in the buttock and thigh area, but canalso be found in the retroperitoneal portions of the body. On grossexamination, the well-differentiated form looks like a routine intra-muscular lipoma, but microscopically the pathologist must find afew areas of low grade lipoblasts with a signet ring appearanceto make this diagnosis. This lesion is sometimes referred to as anatypical lipoma because its gross appearance is similar to the benignlipoma. The prognosis for this variant is extremely good but with afairly high potential for local recurrence in about 30-50% of cases.There is essentially no chance of this lesion metastasizing to distantparts. If located in the retroperitoneal area, it can be fatal becauseof the difficulty in removing the tumor.
  154. 154. CLASSICCase #283Coronal T-1 MRI63 year femaleWell-differentiatedliposarcoma thigh
  155. 155. Resected surgical specimen
  156. 156. Case #284Coronal T-1 MRI49 year male withwell-differentiatedliposarcoma (atypical lipoma)distal thigh
  157. 157. Sagittal T-1 MRI
  158. 158. Axial T-2 MRI
  159. 159. Case #1198 Axial T-2 MRI 62 year male with well-differentiated liposarcoma thigh
  160. 160. Coronal T-2 MRI
  161. 161. Case #1198.1 Dedifferentiated lipsosarcomaCoronal T-1 MRI ofthe thigh of a 41 yearmale with prior historyof partially resectedatypical lipoma 3 yrsbefore
  162. 162. Axial PD Axial Gad
  163. 163. Sagittal Gad
  164. 164. MyxoidLiposarcoma
  165. 165. 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 40and 50 years of age. It occurs in the lower extremities in 75% ofcases, especially in the popliteal area. These lesions are slowgrowing and frequently asymptomatic in the early stages. Onimaging studies, the MRI is the best method for visualizing thesetumors that will have a mixed high and low signal on the T-1weighted image because of the high percentage of fatty tissue inthe tumor. Histologically, there will be evidence of malignantlipoblasts and it is common to find a plexiform network of smallcapillary tubes running thru the fatty tumor, similar to the capillaryhemangioma. The prognosis for this variant is quite good after awide local surgical resection, followed in most cases by localradiation therapy. The chance of pulmonary metastases runs ashigh as 20% and occasionally there will be multifocal myxoid
  166. 166. liposarcomas occurring in the extremities as well as in the retro -peritoneal locations. Occasionally, one will see a transitionalform of myxoid converting into a higher grade round cell lipo-sarcoma which carries a more guarded prognosis.
  167. 167. CLASSIC Case #285 Sagittal T-1 MRI 67 year female with myxoid liposarcoma knee
  168. 168. Sagittal T-2 MRI
  169. 169. Axial T-2 MRI
  170. 170. Resection specimen
  171. 171. Photomic showing lipoblasts and vascular channels
  172. 172. Case #286 Sagittal T-2 MRI tumor 43 year male with myxoid liposarcoma behind knee
  173. 173. tumorCoronal T-2 MRI
  174. 174. tumorAxial T-1 MRI
  175. 175. Surgical resection
  176. 176. Cut specimen
  177. 177. lipoblastsvessel Photomic
  178. 178. Case #287 tumorCoronal T-1 MRI29 year male withmyxoid liposarcomaposterior thigh
  179. 179. tumor Axial PD MRI
  180. 180. Axial T-2 MRI
  181. 181. Wide resection specimen
  182. 182. Photomic showing numerous vascular channels
  183. 183. Case #288 Coronal T-1 MRI 34 year female with myxoid liposarcoma thigh
  184. 184. Coronal T-2 MRI
  185. 185. tumorAxial T-1 MRI
  186. 186. Axial T-2 MRI tumor
  187. 187. Photomic
  188. 188. tumor kidneyAxial T-2 MRI showing multifocal involvement in abdomen
  189. 189. Case #289Sagittal T-1 MRI32 year male with tumormyxoid liposarcomadistal thigh
  190. 190. tumorAxial T-1 MRI
  191. 191. Resected specimen
  192. 192. fatmyxoid Specimen cut in path lab
  193. 193. Photomic
  194. 194. Case #119930 year male withmyxoid liposarcomaposterior thighSagittal T-1 MRI
  195. 195. Sagittal T-2 MRI
  196. 196. tumorAxial T-1 MRI
  197. 197. Axial Gad contrast MRI
  198. 198. Coronal Gadcontrast MRI
  199. 199. Surgical specimen
  200. 200. Photomic
  201. 201. Case #1200 Sagittal T-1 MRI 75 year male with myxoid liposarcoma foot
  202. 202. Another sagittal T-1 MRI
  203. 203. tumorAxial T-1 MRI
  204. 204. Sagittal T-2 MRI
  205. 205. Another sagittal T-2 MRI
  206. 206. Sagittal Gad contrast MRI
  207. 207. Photomic showing lipoblasts
  208. 208. Case #1201 CT scan tumor 69 year male with myxoid liposarc pelvis
  209. 209. Axial T-2 MRI
  210. 210. Photomic showing lipoblasts and vessels
  211. 211. Case #1201.127 year male withmyxoid liposarcomavastus intermedius m. Axial T-1 MRI
  212. 212. Coronal T-1 MRI
  213. 213. Coronal Gadcontrast MRIshowing femoralartery
  214. 214. Surgical incision including biopsy site
  215. 215. biopsySurgical exposure of tumor contained in muscle fascia
  216. 216. Tumor excised including periosteum
  217. 217. biopsy siteExcised tumor mass contained in muscle fascia
  218. 218. Wound closure
  219. 219. Round CellLiposarcoma
  220. 220. Round cell and Pleomorphic Liposarcoma The round cell and pleomorphic liposarcomas are high gradeliposarcomas seen in the same locations as other liposarcomas ina slightly older age group. They account for about 10% of allliposarcomas. Because these are high grade they act more like ahigh grade MFH with increased pain and rapid growth. On imagingstudies, the higher grade lesions take on the appearance of a moreaggressive sarcoma without the high signal appearance of fat onthe T-1 weighted image. Histologically, there will be evidence ofsevere atypicism and bizarre-appearing giant cells with onlyoccasional areas of lipoblastic signet ring cells that are necessaryto make the ultimate diagnosis. These high grade lesions are treatedby wide surgical resection, followed by postoperative radiationtherapy and occasionally chemotherapy will be indicated foraggressive lesions in a younger age group. The chance ofpulmonary metastases runs as high as 80% in these high gradevariants.
  221. 221. CLASSICCase #29038 year male withhigh grade round cellliposarcoma thigh
  222. 222. Sagittal T-1 MRI tumor
  223. 223. Sagittal T-2 MRI tumor
  224. 224. tumorAxial proton density MRI
  225. 225. Photomic showing round cells and lipoblasts
  226. 226. PleomorphicLiposarcoma
  227. 227. CLASSIC Case #291 Sagittal T-2 MRI tumor 44 year male with pleomorphic liposarcoma knee
  228. 228. tumorSagittal T-1 MRI
  229. 229. tumorAxial gad contrast MRI
  230. 230. Photomic showing bizarre pleomorphic giant cells
  231. 231. Close up of pleomorphic lipoblasts
  232. 232. Case #120280 year male withpleomorphic liposarcomaSagittal T-1 MRI
  233. 233. Sagittal T-2 MRI
  234. 234. Surgical specimen
  235. 235. Photomic
  236. 236. Case #120361 year male withpleomorphic liposarcomabiceps muscleSagittal T-1 MRI
  237. 237. Sagittal T-2 MRI
  238. 238. 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
  239. 239. Sag CT scan Cor CT
  240. 240. Axial T-1 T-2fluid tumor Gad
  241. 241. Sag T-2 Surgical specimen
  242. 242. Vascular Tumors
  243. 243. Hemangioma
  244. 244. Hemangioma After the benign lipoma, the benign vascular tumor is the secondmost common soft tissue lesion seen in the human body. Hemangiomasare developmentally dysplastic neoplasms of the endothelial tube.They occur most commonly during childhood, more commonly infemales than males, and account for 70% of all benign tumors. Themost 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 firstfew weeks after birth. The lesion will grow rapidly for a period ofseveral months and then disappear spontaneously over a period ofseven years in about 80% of cases. These lesions are essentiallycosmetic and do not deserve any aggressive form of treatment.However, in the past, attempts at injecting them with sclerosingagents or liquid nitrogen, or using radiation therapy, made thesituation more disabling than the original lesion. A less common
  245. 245. form of hemangioma is the so-called cavernous hemangioma thathas a purplish-gray appearance and can look similar to varicositiesin the extremities but in a younger age group. They can involvelarge muscle groups in the extremity and can even involve synovialmembranes in joints. Radiographically, the hemangioma may present with small,punctate, calcific deposits within the tumor that is almost diagnosticof this condition. These are referred to as phleboliths. The use ofMRI technology is very helpful in making the diagnosis of a hem-angioma and the characteristic sharp mixed signal serpinginouspattern is seen clearly on the T-1 weighted images. As with thecutaneous hemangioma, the larger intramuscular hemangiomas inchildren are not very disabling but can create symptoms of paincaused by spontaneous hemorrhage into the lesion with minimalblunt trauma. The pain symptoms can usually be treated with icingdown for the first 24 hours, followed by compressive dressings fora period of two weeks, after which the patient returns to normal
  246. 246. activity. There may be a recurrence of these clinical symptoms onceor twice a year. Sometimes repeated hemorrhage into an intra-muscular hemangioma can result in fibrotic contracture withdeformity of the adjacent joint that might require a surgical releaseto correct the deformity. An example of this is equinous deformityof the foot caused by a hemangioma of the gastroc muscle. In thepast, attempts have been made to eradicate these larger tumors inmuscle with embolization technique, attempting to occlude the feedervessels. This can lead to compartment syndrome, severe contracturesand loss of muscle strength that can be more severe a disability thanthe original lesion. Wide surgical resection is extremely difficultbecause of the poorly defined margin to the hemangioma and, as aresult, local recurrence is common, followed by intramuscularhemorrhage and associated pain. In some cases with very largehemangiomas, amputation is indicated when severe loss of functionoccurs. It is extremely rare for a malignant conversion to occurwithin a benign vascular dysplasia.
  247. 247. CLASSICCase #292 14 year female hemangioma foot
  248. 248. AP x-ray showingphleboliths
  249. 249. Lateral x-ray showing more phleboliths
  250. 250. tumorAxial T-1 MRI
  251. 251. tumorAxial T-2 MRI
  252. 252. Gross specimen with hemorrhagic cysts
  253. 253. Photomic
  254. 254. Case #29336 year femalehemangioma hand
  255. 255. X-ray showing calcifying mass
  256. 256. AP and oblique views
  257. 257. Surgical removal
  258. 258. Photomic showing cavernous vascular spaces
  259. 259. Case #294 30 year female with hemangioma hand
  260. 260. Case #295 phlebolith8 year female withhemangioma distal arm
  261. 261. Lateral view
  262. 262. Coronal T-1 MRI Coronal T-2 MRI
  263. 263. Sagittal T-1 MRI Sagittal T-2 MRI
  264. 264. Axial T-1 MRI Axial T-2 MRI
  265. 265. bonePhotomic showing large vascular spaces
  266. 266. Case #295.1 Recurrent hemangioma phleboliths 24 year female with recurrent hemangioma triceps
  267. 267. Coronal T-1 T-2
  268. 268. Sagittal T-1 T-2
  269. 269. Axial T-2T-1 Gad
  270. 270. Case #29624 year female with hemangioma forearm with phleboliths
  271. 271. Case #297 phlebolith6 year femalehemangioma forearm
  272. 272. Case #297.1 Hemangioma forearm Cor T-1 Gad 18 year old female with forearm mass for years
  273. 273. Axial T-1Axial Gad
  274. 274. Case #29810 year female with ahemangioma distalleg and footSagittal T-2 MRI
  275. 275. Axial T-2 MRI
  276. 276. Sagittal T-1 MRI foot
  277. 277. Sagittal T-2 MRI
  278. 278. Axial T-2 MRI
  279. 279. HemangiomaCase #298.115 year male with tendermass lateral side of forefootfor many years
  280. 280. Axial T-1 T-2
  281. 281. Sag T-1 T-2
  282. 282. Cor T-2
  283. 283. Case #120422 year male withhemangioma anteriorcompartment leg withsubadjacent corticalhypertrophy of tibia
  284. 284. Axial gadcontrast MRI
  285. 285. Coronal T-1 MRI
  286. 286. Case #120538 year female withhemangioma forearmwith hypertrophic responsein subadjacent ulna
  287. 287. Bone scan
  288. 288. bonehypertrophy Axial PD MRI
  289. 289. Axial gad contrast MRI
  290. 290. Sagittal T-2 MRI
  291. 291. Case #120631 year female withhemangioma leg withhypertrophic responsein adjacent fibula
  292. 292. Axial T-2 MRI
  293. 293. Coronal T-1 MRI
  294. 294. Case #1207 tumor calcification 25 year female with hemangioma buttock area
  295. 295. Coronal T-1 MRI
  296. 296. Sagittal T-2 MRI
  297. 297. Case #1208 tumor calcification 28 year female with hemangioma gastroc muscle
  298. 298. Sagittal T-1 MRI
  299. 299. Axial T-1 MRI
  300. 300. Case #1208.1 Axial CT scan Sag 43 year old female with tender lump in medial gastroc for years
  301. 301. Axial T-2 Gad
  302. 302. Sag T-1 Gad
  303. 303. Case #1208.2 Sag T-1 PD FS Gad 16 year female with intermittent pain and swelling in calf for years
  304. 304. Axial T-1 T-2Gad
  305. 305. Case #120917 year male withhemangioma inquadriceps muscleAxial T-2 MRI
  306. 306. Case #121014 year female withhemangioma hind footAxial T-2 MRI
  307. 307. Case #121167 year female withsynovial hemangiomahip joint with secondaryerosion of femoralhead and neck
  308. 308. Synovial biopsy showing numerous vascular spaces
  309. 309. Case #1211.1 Synovial hemangioma knee 4 year male with painless mass below the patella 1 yr
  310. 310. Sagittal T-1 Sagittal T-2
  311. 311. Axial T-1 Axial T-2 Axial Gad
  312. 312. Case #1211.2 Synovial hemagioma knee 15 year male with knee pain for 6 months
  313. 313. Coronal T-1 Coronal T-2
  314. 314. Axial T-2
  315. 315. Surgical exposure at time of excisional biopsy
  316. 316. Case #1211.3 Synovial hemangioma knee 68 year old female with soft mass medial knee for years
  317. 317. Cor T-1 T-2 Gad
  318. 318. Sag PD Gad
  319. 319. Axial T-2 Gad
  320. 320. Hemangiomatosis
  321. 321. CLASSICCase #299Stillborn with extensivehemangiomatosis
  322. 322. Upper body showing disappearing bones
  323. 323. Lower half of body
  324. 324. Lower extremity withdisappearing bonesin hemangiomatosis
  325. 325. Case #30025 year femalehemangiomatosisupper extremity withdisappearing bones phleboliths
  326. 326. Case #1212 phleboliths 34 year female with hemagiomatosis forearm
  327. 327. Case #1212.1 39 year male with extensive hemangiomatosis thigh
  328. 328. Coronal T-1
  329. 329. MRIarteriogram
  330. 330. Lymphangiomas
  331. 331. Lymphangioma The Lymphangioma, like the hemangioma, is a hamartomatousdysplastic 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 verysimilar histological appearance. 90% of these lesions will occurbefore the age of two years. There is no sex predominance and themost common locations are the head and neck, axilla, inguinal areaand, in some cases, the abdominal viscera including the liver andspleen. Lymphangiomas can be classified as either the capillary typeor simplex type which are considered cutaneous lesions. Larger,deeper lesions are usually cavernous or cystic in nature and referredto as cystic hygromas.
  332. 332. CLASSICCase #30123 year femalelymphangioma forearmand hand withthumb gigantism
  333. 333. Surgical specimen from forearm
  334. 334. Photomic showing lymphatic channels
  335. 335. Case #3027 month malelymphangiomaelbow
  336. 336. Coronal T-1 MRI
  337. 337. Axial T-2 MRI
  338. 338. Case #303 10 year female with lymphangioma forearm
  339. 339. fluid cystAxial proton density MRI
  340. 340. Axial T-2 MRI
  341. 341. Case #304 Axial T-1 MRI 21 year female with lymphangioma inguinal area
  342. 342. Axial T-1 MRI more distal
  343. 343. Axial T-1 MRI even more distal
  344. 344. Surgical specimen cut in path lab
  345. 345. Photomic with lymphatic channels
  346. 346. Case #121346 year male withlymphangioma armAxial PD MRI
  347. 347. Another T-2 MRIshowing 2 lesions
  348. 348. Coronal T-2 MRI veinshowing lymphangiomanext to cephalic vein
  349. 349. Sagittal T-2 MRI vesselsshowing hygromanext to brachialvessels
  350. 350. Photomic of lymphangioma
  351. 351. Glomus Tumor
  352. 352. Glomus Tumor The glomus tumor and the hemangiopericytoma are vasculartumors that arise from the hemangiopericyte which is a cell at theperiphery of the capillary vascular network whose normal functionis to regulate the flow of blood thru the capillary tube system. There-fore, these are tumors that arise from cells outside the endothelialtube where hemangiomas originate from endothelial cells. Theglomus tumor is a small and usually subcutaneous tumor measuringless than 1 cm in diameter and represents 1.6% of all soft tissuetumors. It occurs equally in men and women between the ages of20 and 40 years. The most common location for the glomus tumoris 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, forearmand foot area are invisible to physical diagnosis and characteristicallypresent with localized lancinating pain that persists in the exactlocation of origin until treated by minimal wide surgical resection.
  353. 353. CLASSIC Case #305 50 year male with glomus tumor thumb
  354. 354. AP x-ray
  355. 355. Surgical removal
  356. 356. bloodPhotomic showing hemangiopericytes
  357. 357. Case #306 45 year female with glomus tumor web space hand
  358. 358. Case #307 Surgical exposue subcutaneous glomus tumor forearm 45 year female
  359. 359. Hemangiopericytoma
  360. 360. Hemangiopericytoma The hemangiopericytoma arises from the same hemangiopericytesin the capillary system but is a larger tumor seen in more proximalareas, usually a deep tumor in muscle bellies about the thigh orretroperitoneal area of the pelvis. The smaller tumors are usuallybenign but the larger, more aggressive pericytomas can be malignantand therefore deserve more aggressive treatment with wide resectionfollowed by postoperative radiation therapy because of the chance oflocal recurrence.
  361. 361. CLASSIC Case #308 Sagittal T-1 MRI 87 year female with hemangiopericytoma below groin
  362. 362. Another sagittalT-1 MRI
  363. 363. Axial proton density MRI
  364. 364. Cut specimen in path lab
  365. 365. Photomic
  366. 366. Case #309 Coronal T-1 MRI 45 year male with hemangiopericytoma thigh
  367. 367. Axial T-1 MRI
  368. 368. Axial proton density MRI
  369. 369. tumor Axial T-2 MRI
  370. 370. Case #310 Axial T-1 MRI 44 year female with hemgiopericytoma thigh
  371. 371. tumorAxial T-2 MRI
  372. 372. tumorSagittal T-2 MRI
  373. 373. Case #31158 year femalemalignant hemangiopericytomaarm
  374. 374. tumorCoronal T-1 MRI
  375. 375. Coronal proton density MRI tumor
  376. 376. Axial protondensity MRI tumor
  377. 377. Kaposi’s Sarcoma
  378. 378. Kaposi’s Sarcoma Kaposi’s sarcoma is considered to be the most common of allsoft tissue malignant vascular tumors and can be divided into thechronic, lymphadenopathic, transplant associated type, and theAIDS-related type. It is a cutaneous angiosarcoma seen just beneaththe skin, presenting with a characteristic purplish-blue appearance,similar to a cutaneous hemangioma. It occurs most commonly inmen and is endemic in Central Africa where AIDS is very prevalent.The most frequent location for the Kaposi’s sarcoma is in the footand ankle area. Microscopically, the tumor has an aggressivevascular pattern but with rare mitoses. However, over a period ofyears the tumor can develop into a high grade angiosarcoma or evenfibrosarcoma. The overall mortality runs between 10 and 20%. Thetreatment usually consists of local radiation therapy or surgicalresection if the lesion is localized.
  379. 379. Case #312 75 year female with Kaposi’s sarcoma foot
  380. 380. Plantar view
  381. 381. Cut resected specimen
  382. 382. Photomic
  383. 383. Case #313 65 year male with Kaposi’s sarcoma foot
  384. 384. Photomic
  385. 385. Angiosarcoma
  386. 386. Angiosarcoma The soft tissue angiosarcoma is an extremely rare soft tissuetumor, accounting for less than 1% of all sarcomas. It is usuallya cutaneous lesion that affects males more often than females. Itcan be deeply located, seen typically in the upper extremitiesof women who have had chronic lymphedema following radicalbreast surgery and radiation therapy. The high grade angiosarcomais not a very bloody tumor and does not have the typical vascularspaces seen in benign vascular tumors or low grade intermediateangiosarcomas. The prognosis for the high grade angiosarcoma isvery poor, especially for older people, and the treatment usuallyconsists of wide local resection and postoperative radiationtherapy.
  387. 387. CLASSIC Case #314 Sagittal proton density MRI 30 year male with high grade angiosarcoma heel
  388. 388. Coronal T-2 MRI
  389. 389. Sagittal proton density MRIMetastasis to inguinal lymph node
  390. 390. Sagittal T-2 MRI of positive lymph node
  391. 391. Low power photomic
  392. 392. Higher power showing pleomorphic giant cells around vascular spaces

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