ultrasound and color Doppler in evaluation of musculoskeletal soft tissue masses

1. V

2. RoleofultrasoundandcolorDopplerin
evaluationofmusculoskeletalsofttissue
masses
By
Dr. Amr Osman Osman
Supervisors
Assistant prof. Dr. Ahmed Mohamed Wafaie
Dr. Nevien Ezzat El Liethy

3. Introduction

4. • Soft tissue masses on the extremities and trunk are common
presentations to physicians and surgeons.
• It is necessarily to establishing the exact relationship of the
mass with the muscle and or the tendon .
• Combining grayscale ultrasound with Doppler imaging allows
unique real-time evaluation of regional blood flow, which
may be altered in a variety of disease processes. It can also
help differentiate solid from cystic lesions.
• Diagnostic capabilities of US continue to increase and
become more refined with the improved its technology.

5. AimofWork

6. • To evaluate the usefulness and highlight the indications,
advantages and disadvantages of high-resolution grayscale and
color Doppler ultrasound evaluation in musculo-skeletal soft
tissue masses .
• To assess in differentiation of benign from malignant masses.

7. Normalsonographicanatomy

8. • Skin and Subcutaneous Tissue :
• The epidermis and dermis (black
arrow) are homogeneously
hyperechoic.
• The subcutaneous tissue
(double arrow) includes a
hypoechoic background
reflecting fat lobules (asterisks)
and hyperechoic strands
(arrowheads) due to connective
septa.
• Using transverse 17–5 MHz US image demonstrates the three tissue layers :

9. • Skin and Subcutaneous Tissue :
• The apposed superficial
fasciae appear hyperechoic
(white arrow).
• Subcutaneous veins and
nerves. a Transverse 12–5
MHz US image obtained over
the posterior calf
demonstrates the small
saphenous vein (white
arrowhead) and the adjacent
sural nerve (black arrowhead)
running in the deep
subcutaneous tissue.

10. • Muscle and tendon
• Long-axis and short-axis 12–5 MHz US images of the normal tibialis anterior muscle
• The aponeurosis (straight arrows)
appears as a highly reflective linear
echo within the muscle that is thicker
than the fibroadipose septa (curved
arrow).

11. • Intramuscular aponeuroses
(arrowheads) demonstrate the
feather-like arrangement of a
circumpennate muscle .
• The convergence of the
fibroadipose septa
upon the internal aponeurosis.
• Muscle and tendon

12. • Nerves
•Short-axis and long-axis 15–7 MHz US images over the median nerve at the mid-forearm.
• The nerve fascicles (white
arrow) are depicted as
well-circumscribed
individual structures of
different size
• Separated by internal
echogenic epineurium
(arrow heads).
• The external epineurium
(open arrow heads) helps
to define the outer
boundaries of the nerve.

13. • Nerves
• The nerve fascicles (white
arrow) are depicted as
well-circumscribed
individual structures of
different size
• Separated by internal
echogenic epineurium
(arrow heads).
• The external epineurium
(open arrow heads) helps
to define the outer
boundaries of the nerve.

14. • Bones and joints
Longitudinal 12–5 MHz US image obtained
over the diaphysis of the radius
With radiographic correlation
US appearance of normal bone surface echotexture.
The bone surface as a continuous straight hyperechoic line (arrows) produced
by a strong reflection of sound due to the marked difference in acoustic
impedance of the soft tissues and bone. Reverberation artifact (arrowheads)
projecting in the shadow beyond the bone can be seen.

15. Evaluationofsofttissuemassesinmusculoskeletalsystem
Roleofgreyscaleultrasound:
•Location :
•label surrounding anatomy.
•Compare to the other side
•Measure
in 3 planes:
Anterior-posterior .
Longitudinal
Transverse.
Tumor size was defined as large ( > 5 cm)
medium (1–5 cm)
or small ( < 1 cm)
•Volume calculation = 0.5 X A X B X C
A
B C

16. • Texture:
homogenous , heterogeneous, simple
or complex.
• Echogenicity:
(hypo, hyper , isoechoic ,anechoic)
compared to the surrounding tissue.
 calcifications.
its composition was solid, cystic,
septated or if there is necrotic content

17. •Margins :
Were assessed as well-defined (clear-cut and thin
capsule-like), ill-defined (uncertain margin with respect to
adjacent normal tissue) or infiltrated (certain irregular
margin with adjacent normal tissue and wider transitional
zone)
Check the lump for spread into the muscle:
Has it broken the fascia, the skin or invasion
anywhere else
Is it compressing/displacing any vessels or ducts
•Shape :
Was defined as round, ovoid, lobulated or scalloped
Shadowing ,posterior enhancement or no change.
•Dynamic assessment during contraction and
relaxation of the structure of interest is essential .


18. Roleofspectral,color&powerDopplerultrasound:
The use of a spectral Doppler trace can confirm if the Doppler signal
is artifactual, as a phasic waveform should be obtained if there is true
flow. Furthermore the spectral trace allows differentiation of arterial
from venous flow and allows measurement of parameters such as
the resistive index .

19. Pathologyof
musculoskeletalsoft
tissuetumors

20. Subcutaneous
Intermuscular & Intramuscular
Intraarticular/ Juxtaarticular
Tumor like masses

21. Demonstrative
Cases

22. Subcutaneous
• Angiomatous lesions
• DFSP (dermatofibrosarcoma protuberans)
• Granuloma annulare
• Leiomyosarcoma
• Lipoma
• Lymphoma
• MFH (malignant fibrous histiocytoma)
• Metastasis (especially melanoma)
• Myxoma
• Nodular fasciitis
• Skin appendage tumor

23. Subcutaneous
• Angiomatous lesions :
Angiomatous lesions can be divided
into the following categories:
o Hemangioma
o Lymphangioma
o Glomus tumor

24. Subcutaneous
Hemangioma
Hemangioma of the elbow. Heterogeneous compressible hypoechoic ill-
defined mass (a) with diffuse vascular pools at PD (b)

25. Subcutaneous
Lymphangioma
Cystic lymphangioma in an 8-year-old boy. (A) Grayscale ultra-sonography shows an
ill-defined heterogeneous echoic mass (arrows) with a cystic component
(arrowheads). (B) Color Doppler ultrasonography reveals vascularity within the lesion
but not in the cystic part.

26. Subcutaneous
Glomus tumor
Glomus tumor in a 76-year-old man who complained of a painful nodule in his right index finger.
(A) Grayscale ultrasonography shows a homogeneous hypoechoic nodule (arrowheads) in the
ulnar aspect of the distal interphalangeal joint of the right index finger.
(B) Color Doppler ultrasonography reveals marked hypervascularity within the lesion.

27. Subcutaneous
Lipoma
Lipoma in a 54-year-old woman who complained of a palpable nodule in
her left medial arm for more than 1 year. Longitudinal section
ultrasonography shows a heterogeneous echoic nodule with well-defined
margins (arrows) in the left medial arm; parallel echogenic lines
(arrowheads) were observed within the tumor.

28. Subcutaneous
Lipoma
Subcutaneous lipoma of the scalp : it appears as a well defined homogenous hyper
– isoechoic oval shaped mass lesion is seen which is encapsulated , by CDUS shows
avascular content .

29. Subcutaneous
Lymphoma
A 72-year-old man complained of a painful mass in his right proximal tibial region for 3
months. (A) Grayscale ultrasonography reveals a heterogeneous echoic lesion (arrows) with
ill-defined margin in the anterior tibial region. (B) CDUS shows marked hypervascularity within
the tumor. The arrowheads indicate lymphoma cell infiltration to the subcutaneous fat lobule.
Ultrasonography-guided biopsy revealed a large B-cell lymphoma

30. Subcutaneous
MFH (malignant fibrous histiocytoma)
Malignant fibrohistiocytoma in a 78-year-old man who complained of a painless mass in his right
lateral thigh. (A) Longitudinal ultrasound section reveals a heterogeneous hypoechoic mass
(arrows). (B) Color Doppler ultrasonography shows hypervascularity.

31. Subcutaneous
• Metastasis (especially melanoma)
Subcutaneous metastasis of the thigh
from melanoma. Two hypoechoic
subcutaneous nodules can be identified
Subcutaneous metastasis of the abdominal
wall from lung cancer. Large hypoechoic
nodule with moderate and irregular vascular
signals at directional CD

32. Subcutaneous
• Myxoma
Myxoma. A hypoechoic encapsulated mass was incidentally discovered . This extended field-of-
view longitudinal ultrasound image shows the mass in the plane between the rectus femoris
and vastus intermedius muscles, containing cystic components (arrow) and surrounded by fat.
differential diagnosis with neurogenic
tumors challenging although, unlike these,
myxomas are hypovascular by CDUS and are
not found in continuation with a nerve .

33. Subcutaneous
• Skin appendage tumor
Epidermoid cyst. A heterogeneous nodule is present in the subcutaneous fat of
the back in this patient, abutting and mildly distorting the overlying dermis (D)
and displaying a characteristic lamellated appearance with foci of calcifications.

34. Inter-muscular &
Intra-muscular
• Liposarcoma (myxoid and higher grade)
• Fibromatosis
• Ganglion
• Neurogenic tumors
• Synovial cyst
• Synovial sarcoma
• Leiomyosarcoma
• Nodular fasciitis

35. Inter-muscular &
Intra-muscular
• Liposarcoma (myxoid and higher grade)
Liposarcoma in a 70-year-old man who complained of a progressively swelling mass on his left
elbow. Grayscale ultrasonography reveals a heterogeneous hypoechoic mass (arrows) with a
homogeneous hyperechoic area (arrowheads) on the left elbow .

36. Inter-muscular &
Intra-muscular
• Fibromatosis (superficial)
Plantar fibromatosis. Longitudinal extended field of- view image of the plantar aspect of the
foot shows an elongated heterogeneous nodule (arrow) expanding the distal plantar fascia,
whose axis parallels the fascia.

37. Inter-muscular &
Intra-muscular
• Fibromatosis (deep) desmoids tumor
Desmoid tumor : an Oval, ill-defined hypoechoic nodule within the soft tissues of
the back of the neck with posterior acoustic enhancement. Color Doppler
evaluation reflects no vascularity.

38. Inter-muscular &
Intra-muscular
• Neurogenic tumors
Benign
• Traumatic neuroma
• Morton neuroma
• Neurilemoma (benign schwannoma)
• Neurofibroma, solitary
• Neurofibromatosis
• Localized
• Plexiform
• Diffuse
Malignant
• Malignant schwannoma
• Peripheral tumors of primitive neuroectodermal
tissues

39. Inter-muscular &
Intra-muscular
• Neurogenic tumors
Stump neuromas : A patient with history of
below knee amputation developed pain in two
locations along the stump. The more typical
appearance of posttraumatic or postsurgical
neuromas is that of a discrete hypoechoic
nodule .
Neuroma from amputation. Bulbous
hypoechoic mass at the distal end of a
nerve in the thigh of a patient
operated on for sarcoma avascular or
hypovascular on CDUS

40. Inter-muscular &
Intra-muscular
• Neurogenic tumors
Benign nerve sheath tumor : Low echogenicity mass with extend proximally and distally in a
fibrillar echogenic band corresponding to the nerve axis (arrows).

41. Inter-muscular &
Intra-muscular
• Neurogenic tumors
3D CT reconstruction shows
the displacement of the
vascular structures
adjacent to the mass
By CDUS it shows simple non branching
vessel in the mass shown on power
Doppler.

42. Inter-muscular &
Intra-muscular
• Neurogenic tumors
We have to check for possibility of malignant transformation : Peripheral neurologic
symptoms ? as hypotrophy of the muscles that depend on the diseased nerve , Malignant
forms generally reach a significant size (>5 cm) and have irregular and infiltrating margins and
a heterogeneous internal structure with hypo-anechoic necrotic areas

43. Inter-muscular &
Intra-muscular
• Neurogenic tumors
Plexiform neurofibroma in a woman 33 years of age with neurofibromatosis 1. A,B:
Long (A) and short (B) axis sonograms show plexiform morphology with diffusely
thickened nerve (arrows), with higher echogenicity centrally (smaller asterisks), and
lower echogenicity peripherally (larger asterisks).

44. Inter-muscular &
Intra-muscular
• Synovial sarcoma
synovial sarcoma: A 47-year-old woman complained of a painful right popliteal mass.
(A) Grayscale US shows heterogeneous hypoechoic mass (arrows) over the right
posterior thigh, (B) CDUS shows prominent hypervascularity within the tumor.

45. Inter-muscular &
Intra-muscular
• Leiomyosarcoma– rhabdomyosarcoma
a male child with right thigh rhabdomyosarcoma , the ultrasound pattern is
heterogeneous hypoechogenicity, infiltrated margins, lobulated contour, solid content
with cystic/necrotic areas, moderate size with moderate hypervascularity.

46. Intraarticular/ Juxtaarticular
• Lipoma arborescence
• Pigmented villonodular synovitis
• Synovial chondromatosis
• Giant cell tumor of tendon sheath
• Synovial cyst, bursa, ganglion
• Synovial hemangioma
• Tumoral calcinosis
• Synovial sarcoma

47. Intraarticular/ Juxtaarticular
• Synovial chondromatosis
Longitudinal US images obtained at the level of the proximal
interphalangeal joint reveal amorphous calcifications (arrows) filling
the ventral joint recess (arrowheads) between the bone and the flexor
tendons (ft). MPh, middle phalanx; PPh, proximal phalanx.

48. Intraarticular/ Juxtaarticular
• Giant cell tumor of tendon sheath
Giant cell tumor of the tendon sheath in a 50-year-old woman who
complained of a palpable nodule in her right thumb. (A) Grayscale
ultrasonography shows an ovoid-shaped hypoechoic nodule (arrowheads)
along the extensor tendon. (B) Color Doppler ultrasonography reveals
hypervascularity within the tumor.

49. Intraarticular/ Juxtaarticular
• Giant cell tumor of tendon sheath
Giant cell tumor of tendon sheath: Focal hypoechoic nodule intimately
associated with the adjacent linear striated tendon is characteristic.

50. Intraarticular/ Juxtaarticular
• Giant cell tumor of tendon sheath
Corresponding anteroposterior standard radiograph. Observe the mass effect (asterisk) caused by
the tumor on the soft tissues of the lateral side of the finger. Early signs of bone erosion can also
be appreciated .

51. Intraarticular/ Juxtaarticular
• Synovial cyst, bursa, ganglion (Popliteal cyst)
Popliteal cyst. Cystic distension of the gastrocnemius semimembranosus bursa, which appears as
a well-defined relatively homogeneous anechoic mass with a neck (arrow) communicating with
the joint space.

52. Intraarticular/ Juxtaarticular
• Synovial cyst, bursa, ganglion (Bursitis )
A 48-year-old man complained of a painful nodule in the olecranon region. (A)
Grayscale ultrasonography shows a heterogeneous hypoechoic cystic area (arrows)
with papillary like projections in the olecranon bursa. (B) Color Doppler ultrasound
reveals hypervascularity within its margin denoting bursitis.

53. Intraarticular/ Juxtaarticular
• Ganglion
Power Doppler image shows the close
relation of the cyst to the adjacent radial
artery.
Volar wrist ganglion cyst. (A) Longitudinal ultrasound
image of a bilobed ganglion cyst at the radial volar aspect
of the wrist. A thin neck (labeled) is demonstrated
extending to the volar joint capsule.

54. Intraarticular/ Juxtaarticular
• Ganglion
Ganglion in a 21-year-old woman. Longitudinal section of the dorsal wrist
shows a hypoechoic cystic structure (arrowheads) beneath the extensor
tendon.

55. Tumor like masses :
• Post-traumatic lesions .as muscle tears ,cysts &
hernias
• Muscular abscess
• Idiopathic myositis
• Foreign body retention
• Myositis Ossificans.

56. Tumor like masses :
• Post-traumatic muscle hematoma
Rectus femoris muscle tear. Central hypoechoic mixed intramuscular lesion
(arrowheads) represents a sub-acute hematoma with moderate retraction of
muscle fibers.

57. Tumor like masses :
• Inter-musclar hematoma (different stages)
Intramuscular hematoma of the leg in various stages. (A) Transverse ultrasound image
of acute intramuscular ill-defined hematoma with uniform central echogenicity. (B)
Intramuscular mixed echogenicity collection representing mixed stages of subacute
injury with minimal peripheral vascularity on color Doppler. (C) Anechoic chronic
completely liquefied hematoma in the longitudinal plane.

58. Tumor like masses :
• Post-traumatic muscle hernias
Muscle hernia in a 23-year-old woman who complained of a palpable nodule
in her left lower leg for 1 year. Grayscale ultrasonography shows protruding
muscle fiber (arrowheads) and a defect of the epimysium (arrows) in the left
anterior tibialis.

59. d–g Corresponding transverse 12–5 MHz US images obtained in two
different patients with d,e a large hernia of the tibialis anterior muscle
and f,g a small hernia of the extensor digitorum longus. In both cases (d
and f), part of the muscle (asterisk) bulges through the defect of the
fascia (arrowheads). e,g With probe compression over the defect,
reduction of the hernia is obtained. Arrow, direction of probe pressure.
Muscle hernia. a Photograph
showing the examination technique
for detecting muscle hernias in the
anterolateral compartment of the
leg with US. The patient is asked to
assume a squatting position to
increase the pressure within the
compartment and make the
extruded muscle palpable. Then, the
examiner places the probe over the
lump. b,c Schematic drawings
illustrate the mechanism of hernia
(asterisk) reduction below the
fascial defect by applying pressure
(black arrows) with the probe over
it. Arrowheads, fascial plane.

60. Tumor like masses :
• Myositis ossificans
Well defined disorganized soft tissue mass lesion with heterogeneous internal
architecture, it shows multiple echogenic foci casting distal acoustic shadowing of
calcification . Shows no vascularity on color Doppler

61. Tumor like masses :
• Tumoral calcinosis
(B) Color Doppler ultrasonography
reveals relatively increased vascularity
in the margin of the lesion.
(A) Grayscale ultrasonography shows a
heterogeneous echoic mass (arrows) with
a lobulated cystic lesion and echogenic
calcification (arrowheads) in the left
supra-clavicular region.
Tumoral calcinosis in a 76-year-old male uremia patient who
complained of a painful mass on his left shoulder..

62. Summary
&
Conclusion

63. • Advances in technology and concerns about imaging costs are
expanding the role of sonography in musculoskeletal conditions
especially in evaluating musculoskeletal tumors. Advances in color
flow and power Doppler have further improved the diagnostic
value of Sonography.
• Sonography is a useful and noninvasive imaging modality to
evaluate soft tissue masses. It can be used as a first-line screening
modality to confirm the presence of a soft tissue mass and may
obviate the need for further imaging.
• Ultrasound has proven to be a cost effective and very useful
modality for confirmation, initial assessment, evaluation, as well as
therapeutic and diagnostic interventions of soft tissue masses.
• Combining grayscale ultrasound with Doppler imaging allows
unique real-time evaluation of regional blood flow, which may be
altered in a variety of disease processes and also to help in
differentiate solid from cystic, benign from malignant lesions .

64. • There is some limitations of US ; the most important which is
that US cannot penetrate adult cortical bone ; therefore
medullary involvement of bone marrow cannot be evaluated ,
MRI is superior in clear demonstration of intramedullary
tumoral extension and in determining the exact of origin of the
tumor due to its high contrast resolution and multiplanner
capabilities .
• We can also acknowledge the value of plain radiography; a
suspected bone or soft tissue mass should always commence
with the plain radiograph, it is universally available , easy to
obtain and not expensive . it may not identify the precise
diagnosis but can still provide valuable information like the
presence of calcification and bone involvement .
• Finally, we concluded that US may be a useful imaging modality
in diagnosis of different musculoskeletal soft tissue masses and
we recommend an algorithm for investigating a patient with a
suspected soft tissue tumor.

65. Soft tissue mass
clinical evaluation
and plain radiography
soft tissue mass with no
calcification
Ultrasound
No
mass
soft tissue mass with calcification
 myositis Ossificans
 Tumoral calcinosis
 Calcific tendinitis and bursitis
 Gout
obseve closely
± follow-up x-ray
MRI
?
mineralization
CT
Define a specific clinically
relevant question that may be
answered by the ultrasound
examination as :
o Is there a history of a previous
lesion or underlying malignancy?
o Is the lesion painful, or did the
patient note a painless mass?
o Is there a history of notable
trauma or anticoagulants?
o Has the lesion remained stable
over a long period of time, varied
in size, or is it growing?
o Is there more than one lesion?

66. Soft tissue mass
clinical evaluation
and plain radiography
soft tissue mass with no calcification
Ultrasound
Grey scale , CD & PD
no mass lesion characterised
cystic
ganglion , cyst ,
muscle hernia
hematoma
yes unsure
repeat US
yes
reasure
complex
color Doppler
US
AVM ,
hemangioma
solid
Lipoma, neurofibroma,
etc. as previous
discussed
Indeterminate
diagnosis
MRI
unsure
diagnosis
PET CT
scan &
biopsy
benign
lesion
indeterminate
mass
No further imaging

67. Thank you