This document describes various neurogenic soft tissue tumors including neurilemoma, solitary neurofibroma, neurofibromatosis, malignant schwannoma, rhabdomyosarcoma, alveolar soft part sarcoma, and synovial sarcoma. Specific cases are presented with imaging findings, histology, and treatment details. Neurofibromatosis type 1 is discussed along with its clinical features such as cafe-au-lait spots, plexiform neurofibromas, skeletal deformities, and risk of malignant transformation. Imaging plays an important role in characterizing these lesions and distinguishing between tumor types.

1. Volume 16
Neurogenic soft tissue tumors
Neurilemoma-----------------Case 315-321 & 1214-1220
Solitary neurofibroma--------Case 322-326
Neurofibromatosis------------Case 327-338 & 1221-1229
Malignant schwannoma------Case 339-344 & 1230-1234
Rhabdomyosarcoma------------Case 345-349
Alveolar soft part sarcoma-----Case 350-353
Synovial sarcoma---------------Case 354-363 & 1235-1242
Granular cell tumor-------------Case 1234.1

2. Neurogenic
Tumors

3. Neurilemoma

4. Neurilemoma
The neurilemoma, sometimes referred to as a benign schwanoma,
is a nerve sheath tumor arising from the schwann cell surrounding
the axons of peripheral nerves. It affects individuals between the
ages of 20 and 50 years and occurs equally in males and females. It
is seen most commonly in spinal roots and superficial nerves,
especially on the flexor surface of both the upper and lower limbs.
The lesions are usually solitary but in the case of neurofibromatosis
multiple lesions may occur. These benign lesions are slow growing
and very rarely cause neurological symptoms or defect because
of their benign behavior. As opposed to the more common neuro-
fibroma, the neurilemoma is typically a round structure attached to
the periphery of a nerve whereas the neurofibroma is fusiform in
shape and is located in the center of a peripheral nerve. The MRI
study is the best diagnostic study for this lesion and shows low
signal abnormality on the T-1 weighted image and demonstrates

5. a very bright, well-marginated spherical lesion on the T-2 weighted
image. Histologically, the neurilemoma has a mixture of dense,
fibrotic, Antoni A substance mixed with a more mucinous Antoni B
substance. In the Antoni A fibrotic tissue, the histological picture is a
palisade of schwann cells and a characteristic and almost diagnostic
Verocay body will be seen demonstrating a palisade of schwann cells
as seen in a Japanese lantern. Treatment for this lesion consists of a
simple blunt dissection of the tumor from a peripheral nerve where
it is located eccentrically and easy to remove without damaging the
subadjacent nerve. The lesion has a characteristic yellow color
contrasting with the white strand-like appearance of the adjacent
nerve. These tumors have a very low recurrence rate and only rarely
will they convert into a malignant schwannoma.
Sometimes the neurilemoma will develop hemorrhagic cystic
changes in patients over the age of 65 years, taking on the appearance
of a hematoma. The lesions can even calcify or form bone as part of a
degenerative process, and are sometimes given the name of ancient
schwannoma in this case.

6. CLASSIC Case #315
Coronal T-1 MRI
gluteus max
55 year male with neurilemoma proximal sciatic nerve

7. Axial T-2 MRI

8. gluteus
tumor
nerve
Sagittal T-2 MRI of tumor in sciatic nerve

9. tumor
gluteus
nerve
Surgical exposure of tumor on sciatic nerve

10. Photomic of highly cellular Antoni A area

11. Verocay body
Close up of Antoni A area

12. Case #316 Axial T-1 MRI
22 year female with neurilemoma sciatic nerve

13. tumor
Axial T-2 MRI

14. tumor
Coronal T-2 MRI

15. Coronal gad contrast MRI showing large cystic areas

16. cyst
Axial gad contrast MRI

17. Case #317
69 year male
calcifying neurilemoma
ulnar nerve

18. nerve
tumor
Sagittal T-1 MRI showing tumor in ulnar nerve

19. nerve
tumor
Sagittal T-2 MRI

20. Axial T-2 MRI showing calcific signal voids

21. Surgical specimen

22. Photomic from Antoni A area

23. Case #318
36 year male with neurilemoma S-1 root

24. Lateral view

25. L-5
Sagittal T-1 MRI
tumor

26. Sagittal PD MRI

27. S-1 root
S-1
tumor
Coronal T-2 MRI

28. tumor
S-1 foramen
Coronal T-1 MRI

29. Case #319
24 year female S-2
neurilemoma S-2
tumor
Sagittal PD MRI

30. S-1
Another sagittal
PD MRI cut
tumor

31. tumor
cystic area
tumor
Sagittal T-2 MRI

32. cystic area
Sagittal gad contrast MRI

33. cyst
S-2
Axial gad contrast MRI

34. Case #319.1
66 year male with painless presacral tumor mass for 7 years

35. Axial
T-1 T-2
Gad

36. LBP MRI
Sag T-1 in 99 Sag T-1 in 06 Sag T-2 in 06

37. Cor Gad C+

38. Case #320
45 year male
dumbell neurilemoma
C-3-4

39. Myelographic study
showing extradural
defect

40. Case #321
28 year male with
ossifying ancient
neurilemoma tibia

41. Lateral view

42. Case #321.1
86 year female with ancient schwannoma popliteal space

43. Sag T-1 Sag PD Sag Gad

44. Cor T-2 Cor Gad

45. Axial
T-1 T-2
Gad

46. Case #1214
CT scan
37 year male with neurilemoma S-1

47. L R
Bone scan shows signal void S-1 on left side

48. Sagittal PD MRI

49. Coronal PD MRI

50. Case #1215
42 year male with
neurilemoma L-5
with lysis of L-5
pedicle

51. Lateral view

52. CT scan

53. Another CT scan

54. Case #1216 Coronal T-1 MRI
36 year female with neurilemoma brachial plexus C5-6 roots

55. Coronal T-2 MRI

56. Case #1217 Axial T-2 MRI
48 year male with neurilemoma radial nerve

57. Sagittal T-2 MRI

58. Surgical specimen cut in path lab

59. Case #1217.1
Sag T-1 PD Gad
51 year female with 1 yr history of tingling in right thumb

60. Axial T-1
PD
Gad

61. Radial N.
Cor STIR Surgical excision

62. Case #1217.2
Cor T-1 PD Gad C.
46 year female with tender mass located along ulnar nerve

63. Axial T-2
Axial Gad

64. Case #1217.3 Axial PD FS Gad
Upper
Lower
36 yr female with two separate lumps in one leg for 1 year

65. Sag T-1 Gad Gad

66. Surgical specimen

67. Case #1218
36 year male with
neurofibromatosis and
a neurilemoma in the
sciatic nerve
Axial T-1 MRI

68. Sagittal T-1 MRI

69. Sagittal T-2 MRI
showing tumor arising
from sciatic nerve

70. Axial T-2 MRI

71. Case #1220.1
Axial PD MRI
65 year male with tender lump low in popliteal space 1 yr

72. posterior
tibial art
Coronal T-1 Coronal PD

73. Post tibial
nerve
Sagittal T-1 Sagittal PD

74. Surgical exposure of the neurilemoma in the post. tib. N.

75. Post tibial N.
Surgical removal of the neurilemoma

76. Case #1220.2 Sag T-1 T-2 Neurilemoma
63 year female with tingling on bottom of foot for 6 months

77. Axial T-1 T-2

78. Cor T-1 T-2

79. Surgical excision

80. Case #1220.3 Sag T-1
42 year male with
tender lump bottom
of foot for 1 year
Gad

81. Axial T-1 T-2 Gad

82. Solitary
Neurofibroma

83. Solitary Neurofibroma
The solitary neurofibroma, as opposed to the neurolemoma, is
usually a fusiform, sweet potato shaped peripheral nerve sheath
tumor that arises centrally from the mid-portion of a peripheral nerve.
The lesions are usually small and located in a subcutaneous location.
They are seen between the ages of 20 and 30 years in males and
females equally, and are ten times more common than the neuro-
fibromas seen in Von Reckinghausen’s neurofibromatosis. On MRI,
the lesions are low signal on T-1 and very bright on T-2, and some-
times can be seen arising from a small peripheral nerve. Histo-
logically, the lesions have dense Antoni A substance with palisading
schwann cells, similar to that seen in the neurilemoma. Treatment
consists of simple surgical resection and the recurrence rate is low. A
specific reactive type neurofibroma occurs in the foot between the
third and fourth toes, in the common digital nerve in the web space.
It arises as a result of recurrent compression trauma from wearing

84. tight shoes. This type of neurofibroma, seen typically in females,
can be resected surgically for pain. The so-called amputation
neuroma is a bulbous traumatic neurofibroma seen at the end of
an amputation stump where the peripheral nerves have been
transected during the amputation.

85. CLASSIC Case #322 Sagittal PD MRI
32 year female with neurofibroma foot

86. Axial STIR MRI

87. Surgical exposure for excision

88. nerve
Surgical specimen cut in path lab

89. Photomic showing palisading of schannoma cells

90. Case #323 Sagittal T-1 MRI
tumor
3 month old infant with neurofibroma foot

91. Sagittal PD MRI

92. Axial T-2 MRI

93. Another axial T-2 cut

94. Case #324
Coronal PD MRI
53 year male with neurofibroma thigh

95. Coronal T-2 MRI

96. Axial T-1 MRI

97. Axial T-2 MRI

98. nerve
Resection specimen cut in path lab

99. Photomic

100. Case #1220 Axial T-1 MRI
56 year female with neurofibroma on sciatic N at notch level

101. Axial T-2 MRI

102. Axial Gad contrast MRI

103. Veracoy body
Photomic in area of Antoni-A tissue

104. Case #1220.1
tumor
53 year female with slow growing pelvic neurofibroma 10 yrs

105. Axial T-1 Axial T-2
tumor
Gad
Sciatic N

106. tumor
Axial T-2 showing origin from both S-1 roots

107. tumor
Coronal Gad

108. Sag T-2

109. Case #325 Plastic cut away model
32 year female with Morton’s neuroma

110. Photomic of traumatic neuroma

111. Case 326 Plastic model cut away
42 year male with amputation neuromata forearm

112. Photomic amputation neuroma

113. Neurofibromatosis

114. Neurofibromatosis (Von Recklinghausen’s disease)
Neurofibromatosis is clinically divided into Type I and type II.
Type I involves peripheral nerves and will be discussed in this
section: type II is the central type consisting of acoustic neuroma
that has nothing to do with peripheral neurofibromatosis. The type I
disease is a familial dysplasia, inherited as an autosomal dominant
trait, with an incidence of about one in every 3000 births. The
condition becomes clinically manifest in the first few years of life
with the presence of café-au-laite spots that increase in number and
size over time. Unlike the café-au-laite spots seen in fibrous
dysplasia, the ones in neurofibromatosis have a smooth edge, some-
times referred to as the coast of California. If a patient is found with
more than six lesions with smooth-edged café-au-laite spots greater
than 1-2 cm in diameter, the diagnosis can be made. Later on in life,
the patient will develop numerous cutaneous neurofibromas that
are referred to as fibroma molluscum and have the appearance of

115. small, pedunclated lipomas. The most pathognomic feature of
neurofibromatosis is the large, plexiform neurofibroma associated
with the larger nerves that can involve an entire extremity and can
be associated with loose, hyperpigmented skin that produces an
elephant-like, gross distortion of the skin anatomy referred to as
elephantiasis neuromatosa or elephant man syndrome. Skeletal
deformation can be associated with neurofibromatosis, including
scoliosis (which can be quite angular resulting in paraparesis),
spinal meningoceles, scalloping of vertebral bodies, and pseudo-
arthrosis of the tibia. There can also be associated hypertrophy
or localized gigantism in the hand or foot. As opposed to the
solitary neurofibroma, patients with neurofibromatosis run a 10%
chance of developing a malignant neurofibrosarcoma that usually
occurs during adult life and carries an extremely poor prognosis
for survival.

116. CLASSIC
Case #327
fibroma
molluscum
35 year male type 1
neurofibromatosis with
large plexiform
neurofibroma and
elephantiasis left arm

117. Case #328
11 year male
neurofibromatosis 1
café-au-lait spots &
scoliosis

118. Case #329
Axial T-1 MRI
5 year female with plexiform neurofibromata pelvis

119. tumor
gluteus
Oblique coronal T-1 MRI

120. tumor
Axial T-2 MRI

121. Case #330
Sagittal T-1 MRI
35 year male with neurofibromatosis S-2 & 3

122. Sagittal T-2 MRI
tumor

123. tumor
Axial T-1 MRI

124. tumor
Axial T-2 MRI

125. Case #331
Sagittal T-1 MRI
tumor
19 year female with neurofibromatosis and
neurilemoma sciatic nerve

126. Axial T-1 MRI
tumor

127. tumor
Axial T-2 MRI

128. Case #332 Sagittal T-2 MRI
15 year female with plexiform neurofibromatosis LS spine

129. tumor
Axial proton density MRI pelvis

130. tumor
Sagittal T-2 MRI

131. Case #333 Sagittal T-1 MRI
tumor
45 year male with plexiform neurofibromatosis knee

132. tumor
Sagittal T-2 MRI

133. Case #334
4 year male with
neurofibromatosis and
elephantiasis left arm
café-au-lait spots

134. X-ray with frail bone

135. Case #335
32 year female with neurofibromatosis hands & gigantism

136. Case #336
30 year male with
neurofibromatosis with
gigantism 2nd & 3rd toes

137. Case #337
16 year male with
neurofibromatosis
cervical spine

138. Severe dysplastic changes
in cervical vertebrae

139. Myelographic study
showing multiple
dumbell neurofibromata

140. Sagittal laminogram
showing hypoplastic
vertebrae

141. Case #338
Child with tibial
pseuoarthrosis 2nd
to neurofibromatosis

142. Case #1221 CT scan
55 year female with neurofibromatosis and large
neurofibroma in sciatic nerve at notch level

143. Sagittal T-1 MRI
showing large plexiform
neurofibroma in buttock
area

144. Axial T-1 MRI showing plexiform neurofibroma

145. Axial T-1 MRI at higher level

146. Case #1222
45 year female with neurofibromatosis and plexiform
neurofibroma about heel and ankle area

147. Axial T-1 MRI
showing tumor between
talus and heel cord

148. Coronal T-1 MRI
showing tumor behind
ankle joint

149. Coronal T-2 MRI

150. Sagittal T-2 MRI

151. Case #1223 Sagittal T-2 MRI
8 year male with neurofibromatosis and plexiform
neurofibroma of forefoot

152. Axial T-1 MRI

153. Axial T-2 MRI

154. Coronal T-2 MRI

155. Case #1223.1
26 year male with type I
neurofibromatosis and
large plexiform neuro-
fibroma in foot with
bony deformation

156. Sagittal T-1
T-2

157. Coronal T-1 T-2

158. Axial T-1 T-2
Gad

159. Case #1224
27 year male with neurofibromatosis and secondary
talar gigantism

160. Gigantism of 3rd toe

161. Plexiform neurofibroma deep post compartment leg

162. Plexiform neurfibroma
deep in arch of foot

163. Axial T-2 MRI
plexiform neuro-
fibroma in forefoot
area

164. Sagittal T-2 MRI
plexiform neurofibroma
forefoot area

165. Resected specimen from posterior leg compartment

166. Case #1225
18 year male with neurofibromatosis and plexiform
neurofibroma calf area

167. popliteal vessels
Surgical exposure of tumor in calf

168. Plexiform neurofibromata removed from calf area

169. Surgical incision

170. Case #1226
55 year male with
neurofibromatosis
and associated
deformity rib cage

171. Case #1227
17 year female with
neurofibromatosis and
severe spinal kyphosis
with paraplegia

172. Case #1228
9 year female with
neurofibromatosis with
associated pseudarthrosis
tibia

173. Case #1229
19 year female with
neurofibromatosis and
associated deformation
forearm bones and
radial head dislocation

174. Malignant
Schwannoma

175. Malignant Schwannoma
The malignant schwannoma is a very high grade spindle cell
sarcoma arising from the nerve sheaths of peripheral nerves. It can
arise denovo from a normal appearing peripheral nerve but is more
likely to arise from a solitary neurofibroma. There is a 5 year
survival rate of about 75% in patients over the age of 40 years when
a malignant schwannoma arises from a peripheral solitary neuro-
fibroma. There is a 10% incidence of malignant schwannoma in
patients with neurofibromatosis and the chance for survival at five
years is reduced to 30% and is seen in a younger age group. The
malignant schwannoma is is usually larger than 5 cms and occurs
typically in spinal roots or in the larger proximal nerves such as
the sciatic nerve. The lesions are best picked up by MRI of a painful
mass that occurs in patients with neurofibromatosis and may be
associated with neurological deficits distal to the involved area.
There may also be a café-au-laite spot in the overlying skin. The

176. tumor is usually treated by a wide resection, including the entire
nerve from which it originates, following which local radiation
therapy is recommended to reduce the chance of local recurrence.
Adjuvant chemotherapy is advised even though its benefit is
questionable.

177. CLASSIC
Case #339
tumor
28 year female
malignant schwannoma
sciatic nerve nerve
Sagittal T-2 MRI

178. tumor
Axial PD MRI

179. spinal prep site
SubQ plexiform neurofibroma with café-au-lait spot over pelvis

180. peroneal N sciatic N
tumor
post tib N
Tumor exposed ready for resection

181. benign
malignant
Scanning lens photomic

182. Low power malignant photomic

183. Higher power

184. Case #340
tumor
tumor
16 year female with malignant schwannoma pelvis

185. necrosis
notch
Axial CT scan showing large necrotic tumor
filling the pelvis and extruding thru the sciatic notch

186. Large gluteal mass with café-au-lait spots prior to resection

187. Tumor exposed beneath gluteus maximus

188. Large excised tumor on back table

189. Low power photomic

190. Higher power photomic

191. Case #341
46 year male with skin lesions of neurofibromatosis

192. Close up of fibroma molluscum skin lesions

193. CT scan
tumor
Large malignant schwannoma in adductor compartment

194. tumor
Exposed tumor at time of surgery

195. Excised tumor cut open on back table

196. Low power photomic

197. High power photomic

198. Case #342
25 year male with neurofibromatosis and café-au-lait
spot over buttock and malignant schwannoma sciatic N

199. Surgical exposure of sciatic nerve tumor

200. malignant
benign
Excised cut specimen showing benign and malignant parts

201. Photomic of malignant portion

202. Case #343
Autopsy specimen
Autopsy specimen of 42 year female with neurofibromatosis
and malignant schwannoma in area of severe dorsal kyphosis

203. Sagittal cut autopsy specimen

204. Photomic of tumor

205. Case #344 Sagittal T-2 MRI
26 year female with malignant schwannoma peroneal N

206. Axial T-2 MRI

207. Photomic

208. Case #1230
47 year male with
malignant schwannoma
leg
Coronal T-1 MRI

209. Axial T-2 MRI

210. Surgical specimen

211. Photomic

212. Higher power

213. Case #1231
CT scan
20 year male with malignant schwannoma paraspinous area

214. Axial T-2 MRI

215. Another axial T-2 MRI at different level

216. Case #1232
17 year male with malignant schwannoma thigh

217. CT scan

218. Another CT scan at different level

219. Case #1233
36 year female with
benign meningioma
arising within the
radial nerve
Sagittal T-1 MRI nerve

220. nerve
Sagittal T-2 MRI

221. Axial PD MRI

222. Case #1234
49 year female with myxopapillary ependymoma sacrum

223. CT scan

224. CT scan at lower S-2 level

225. Sagittal T-1 MRI

226. Sagittal T-2 MRI

227. Axial T-2 MRI

228. Granular cell Tumor

229. Granular Cell Tumors
The granular cell tumor is a fairly common soft tissue tumor
that was once thought to be of muscle origin. More recent studies
have proved it to be of neural origin. They are more common in
in males than females and are seen typically in a subcutaneous
location. They are usually painless and less than 3 cm. in
diameter. They are more common in blacks and are seen most
commonly in the fourth thru the sixth decade. By MRI study
the tumors are poorly circumscribed nodular lesions that are low
signal on T-1 and bright on T-2. Histologically the cells have a
benign appearance with a granular appearing cytoplasm. There is
a rare and malignant variant of the granular cell tumor. In the
case of the more common benign form the treatment consists
of simple local excision with little chance of recurrence.

230. Case #1234.1 Axial T-1 Granular cell tumor
T-2 FS
34 year old female with a
painless lump in calf 4 mos
Gad

231. Cor T-1 Gad

232. Sag T-1 T-2 FS Gad

233. Rhabdomyosarcoma

234. Rhabdomyosarcoma
Rhabdomyosarcoma accounts for 20% of all soft tissue sarcomas.
The embryonal and alveolar types are seen in the pediatric age
group while the less common pleomorphic rhabdomyosarcoma is
seen in adults.
The embryonal rhabdomyosarcoma occurs in children between
the ages of 0 and 15 years, and is seen more commonly in boys
than girls, with the head and neck area being the most common
location for this tumor. Histologically, it is a round cell tumor similar
to Ewing’s sarcoma but in 50% of cases there will be evidence of
cross striation in associated spindle cells and the tumor will have
immunohistochemical markers for desmin, myoglobin, and actin.
Prior to the advent of chemotherapy, this tumor was fatal in about
90% of patients, but with current chemotherapy protocols, patients
survive this tumor in over 80% of cases. Treatment consists of local
surgical resection when indicated, along with postoperative radiation
therapy if the surgical margins are considered contaminated.

235. The alveolar rhabdomyosarcoma affects children between the
ages of 10 and 25 years, and is more commonly seen in males than
females. It occurs in the head and neck area, but can also be seen
in the extremities, especially the thigh and calf. Histologically, this
variant has a typical alveolar pattern of round cells that gives it its
clinical name and only rarely will there be rhabdomyoblasts in the
histological specimens. Treatment consists of surgical resection
followed by radiation therapy if the margins are positive, along
with adjuvant perioperative chemotherapy. The prognosis for
survival is much worse than that of embryonal rhabdomyosarcoma.
The pleomorphic rhabdomyosarcoma is the rarest variant of
the group, consisting of 5% of all cases. It occurs in middle-aged
or older patients and is most commonly located in large muscle
groups in the proximal extremities, usually the lower extremities.
In the 1940’s the pleomorphic rhabdomyosarcoma was a common
histological diagnosis that included many cases of MFH which
at that time was an unpopular histologic diagnosis but a common

236. one by current pathological criteria. Microscopically, this variant
consists of large, bizarre-appearing giant cells with very atypical
nuclei. The cells stain positive for glycogen and cross striations are
frequently seen in the so-called “candy ribbon” cellular patterns
with tandem nuclei on the surface of these rectangular cells. This
variant carries a very poor prognosis for survival and the use of
adjuvant chemotherapy is not nearly as effective as it is for the
pediatric variants. The mainstay of treatment is wide local resection
when possible, followed by radiation therapy, even with negative
surgical margins.

237. CLASSIC Case #345 Axial T-1 MRI
9 month male with embryonal rhabdomyosarcoma pelvis

238. Axial T-2 MRI

239. Coronal gad contrast MRI showing central necrosis

240. Another coronal gad contrast cut with necrosis

241. Photomic showing round cells

242. Higher power

243. Case #346
7 year male
embryonal
rhabdomysarcoma
maxilla

244. AP x-ray

245. Low power photomic

246. High power

247. Case #347
7 year female with fungating alveolar rhabdomysarcoma leg

248. Surgical specimen cut in path lab

249. Photomic

250. Case #348
45 year male with pleomorphic rhabomyosarcoma biceps

251. Close up of tumor

252. Lateral x-ray of arm
showing tumor mass

253. Arteriogram showing
tumor blush

254. Surgical exposure during wide resection

255. Tumor cut in path lab

256. Photomic showing strap cells

257. Case #349
42 year female with
pleomorphic
rhabdomysarcoma
hypothenar hand

258. Ulnar amputation
cut in path lab

259. biopsy
Close up photo
tumor

260. Photomic showing large pleomorphic giant forms

261. Remaining functional radial hand

262. Great cosmetic appeal

263. Alveolar Soft Part
Sarcoma

264. Alveolar Soft Part Sarcoma
The alveolar soft part sarcoma is a high grade round cell sarcoma
affecting patients between the ages of 15 and 35 years, with a pre-
dominance for females. The tumor usually arises from deep muscle
tissue in the lower extremities, most commonly in the thigh. This
tumor is a slow growing lesion that carries a very poor prognosis
because of a high potential for pulmonary metastases. It is felt to
originate from neurogenic stem cells, however, its histological
appearance is similar to that of the alveolar variant of the rhabdo-
myosarcoma which has a similar microscopic appearance. Treatment
usually consists of an attempt at wide surgical resection followed
by postoperative radiation therapy, if the margins are positive, and
chemotherapy because of the high incidence of pulmonary metastases
with an overall survival of approximately 50% at five years.

265. CLASSIC
Case #350
22 year female
alveolar soft part
sarcoma pelvis

266. Axial T-2 MRI

267. Wide resection specimen

268. Photomic showing alveolar pattern

269. Post op x-ray with
internal hemipelvectomy
reconstructed with
rebar and cement THA

270. Case #351 Oblique x-ray
45 year female with alveolar soft part sarcoma pelvis

271. CT Scan

272. Sagittal T-1 MRI
tumor
ischium

273. tumor
Axial T-2 MRI

274. Photomic showing alveolar pattern

275. cement
Post op x-ray showing rebar and cement reconstruction

276. Case #352 Axial T-2 MRI
26 year male with alveolar soft part sarcoma thigh

277. Arteriogram
showing tumor blush

278. Low power photomic showing alveolar pattern

279. High power

280. Case #353 Axial proton density MRI
tumor
9 year female with alveolar soft part sarcoma thigh

281. tumor
Sagittal proton density MRI

282. Alveolar pattern on photomic

283. Synovial Sarcoma

284. Synovial Sarcoma
The synovial sarcoma is the fourth most common soft tissue
sarcoma seen in the human anatomy. It occurs typically in young
adults between the ages of 15 and 35 years, affecting males slightly
more than females. The name, synovial sarcoma, suggests an
origin in synovial tissue within a major joint. This is a mistaken
concept because only 10% of these tumors will be found inside a
major joint. They usually occur in juxta-articular structures, most
often around the knee, and are frequently associated with tendon
sheaths, bursal sacs, and fascial planes. They can also occur in deep
muscle bellies. These tumors are also commonly seen about the
thigh, shoulder, arm, elbow and wrist area, and are also found about
the foot area. The synovial sarcoma is unusual in that it usually
starts off with a very slow growth pattern that may suggest a benign
process masquerading as an injury to the extremities. In many cases
there is dystrophic calcification or even heterotopic bone within the
tumor, again suggesting a benign diagnosis that clinicians may

285. inject for symptomatic relief.
Microscopically, this tumor has a characteristic biphasic pattern
with a combination of epithelioid-looking cells that form in nests,
clefts, or even in a tubular structure formation associated with
malignant-appearing spindle cells in the same area. There is a
monophasic form of this sarcoma, usually a spindle cell form, that
has the appearance of a fibrosarcoma. There is also an epithelioid
form of the synovial sarcoma that is quite unusual. Despite the
benign clinical appearance of the tumor, the prognosis for survival
is very poor, with only about 50% of patients surviving for five
years and only 25% surviving ten years. There is a high (20%)
metastatic involvement of proximal lymph nodes that should be
looked for and treated by aggressive resection and local radiation
therapy. In about 30% of cases, there will be heavy calcification
within the tumor that indicates a more benign prognosis with an
80% survival rate at five years in this group.
The treatment for this tumor consists of wide local resection,

286. if possible, or high level amputation for cases where local control
is difficult. Following a wide resection, local radiation therapy is
employed. If the prognosis seems extremely guarded, chemo-
therapy is indicated.

287. CLASSIC Case #354
20 year female with synovial sarcoma shoulder

288. CT scan showing calcifying tumor

289. 3-D CT reconstruction

290. tumor
Coronal T-1 MRI

291. tumor
Axial T-1 MRI

292. tumor
Axial proton density MRI

293. Surgical specimen

294. Photomic showing biphasic pattern

295. Case #354.1 Synovial sarcoma
34 year old male with tender lump in axilla for 6 months

296. Chest x-ray CT scan

297. T-2
Cor T-1
Gad

298. Axial T-1 T-2 FS
Gad

299. MRI Arteriogram

300. Resection specimen

301. Case #355
73 year female with synovial sarcoma proximal thigh

302. Close up x-ray

303. tumor
Axial T-1 MRI

304. tumor
Axial T-2 MRI

305. Photomic showing biphasic pattern

306. Case #355.1 Synovial sarcoma
Axial T-1 T-2
67 year old female with injury to thigh 7 years ago

307. Sag T-1 Sag PD

308. Cor STIR

309. Case #355.2 Synovial sarcoma
55 year male with tender mass in anterior thigh 6 months

310. Coronal MRI
T-1 T-2 Gad

311. Axial
T-2 Gad
Sag T-2

312. Calcific tendonitis gluteus max
Case #355.3
Synovial sarcoma
pseudotumor
41 year female with
left hip pain 3 months

313. CT scan

314. Axial T-1 T-2
Gad

315. Cor T-2 FS T-2 FS Gad

316. Sag T-2 Gad

317. Case #355.4 Calcific deltoid tendonitis
46 year male with severe pain left upper arm for 6 weeks

318. Axial T-1 T-2

319. Case #355.5 Pseudo-synovial sarcoma
61 year male with incidental finding in pelvis

320. Case #356
tumor
25 year male with heavily calcified synovial sarcoma thigh

321. Macro section showing invasion of adjacent femur

322. epithelioid
Spindle cells
Photomic showing biphasic pattern

323. Case #356.1 Synovial sarcoma
11 year male with painless lump posterior medial knee 1 yr

324. Sag T-1 Cor T-2

325. Axial Gad
Axial T-2

326. Case #356.2 MRI Pseudotumor
Cor T-1 Sag T-2
33 yr male with painless popliteal Baker’s cyst present
for 6 months

327. Sagittal PD MRI Axial T-2 MRI

328. Case #356.3 Synovial sarcoma
Axial MRI
T-1 T-2
16 year female with Gad
painful mass anterior to
ankle for 6 months

329. Coronal T-1 T-2

330. Sagittal T-1 T-2

331. Case #357
28 year male with synovial sarcoma foot

332. tumor
Sagittal T-2 MRI

333. tumor
Axial T-2 MRI

334. Photomic showing biphasic pattern

335. Case #358
32 year female with
ossifying synovial
sarcoma great toe

336. Case #358.1
28 yr male with fungating tumor in foot for 6 mos

337. Axial
T-1 T-2
Gad

338. Sag T-1 T-2 FS

339. Cor
T-1 T-2
Gad

340. Case #358.2 Axial T-1
T-2
40 year female with painful forefoot for 1 year

341. Cor T-1
T-2 FS

342. Case #359 Sagittal T-1 MRI
36 year female with synovial sarcoma foot

343. Axial gad contrast MRI
tumor

344. Case #360
30 year female with
synovial sarcoma leg

345. tumor
CT scan

346. Coronal T-1 MRI tumor

347. tumor
Axial T-2 MRI

348. Case #361 Sagittal T-1 MRI
tumor
74 year female with synovial sarcoma ankle

349. Axial STIR MRI
tumor

350. Axial gad contrast
tumor

351. Case #362
22 year male
intra-articular
synovial sarcoma
knee
tumor
Sagittal T-1 MRI

352. tumor
Axial gad contrast MRI

353. Sagittal gad contrast
tumor

354. Resection specimen cut in path lab

355. Scanning lens photomic showing epithelioid lined clefts

356. Case #362.1
Synovial sarcoma
30 year male with 17 year history of slow growing
lump lateral retinaculum right knee

357. Axial T-2

358. Cor T-1 T-2

359. Case #362.2 Tophaceous gout
synovial sarcoma pseudotumor
51 year male with tender prepatellar lump for one year

360. Axial T-1 T-2
Gad

361. Sag T-1 T-2
Gad

362. Case #362.3 Axial T-2 Synovial sarcoma
40 year male with knee pain for 6 months

363. Cor T-1 T-2
PD FS

364. Sag T-2 FS PD FS

365. Case #363
16 year female with
ossifying synovial sarcoma
In a suprapatellar lipoma

366. Synovial sarcoma
lipoma
CT scan

367. tumor
Sagittal T-1 MRI
lipoma

368. Scanning lens photomic showing lipoma to right
and ossifying synovial sarcoma to left

369. Photomic of lipoma portion

370. osteoid
Photomic of ossifying monophasic synovial sarcoma

371. Photomic showing extensive ossification in sarcoma

372. One year after resection
and signs of recurrence

373. Case #1235 Coronal T-1 MRI
34 year female with synovial sarcoma thigh

374. Coronal T-2 MRI

375. Axial T-1 MRI

376. Axial T-2 MRI

377. Photomic showing a biphasic pattern

378. Case #1236
14 year female with
synovial sarcoma thigh
with calcification

379. Axial T-1 MRI

380. Axial T-2 MRI

381. Case #1236.1
Synovial sarcoma
85 year male with soft tissue lump medial thigh 3 mos

382. Axial
T-1 T-2
Gad

383. Cor T-2 Gad

384. Case #1237
35 year male with
calcifying synovial
sarcoma thigh

385. Axial PD MRI

386. Axial T-2 MRI

387. Photomic showing a biphasic pattern

388. Case #1238 Coronal PD MRI
28 year female with synovial sarcoma adductor compartment

389. Case #1239 Coronal PD MRI
18 year female with synovial sarcoma shoulder

390. Another coronal PD MRI cut thru tumor

391. Axial PD MRI

392. Photomic with biphasic pattern

393. Case #1241
45 year female with
calcifying synovial
sarcoma thigh

394. Sagittal T-1 MRI

395. Axial PD MRI

396. Photomic showing monophasic spindle cell pattern

397. Case #1242 Coronal PD MRI
27 year male with synovial sarcoma elbow

398. Axial PD MRI

399. Case #1242.1 Synovial sarcoma
17 year old male with painful mass in elbow for 3 months

400. Sag T-1 T-2 Gad

401. Axial T-1 T-2
Gad