High-Resolution Ultrasound in The Assessment of Soft Tissue Tumors and Tumor-Like Lesions

High-resolution ultrasound in the assessment of soft tissue
tumors and tumor-like lesions
Poster No.: C-1867

Congress: ECR 2013
Type: Educational Exhibit
Authors: 1 1
M. Martínez Hervás , V. de Lara Bendahan , M. D. Moreno
2 1 1
Ramos , J. Vivancos García , M. A. Garcia Sanchez , F. J. Ramos
1 1 2
Medrano ; Sevilla/ES, Bormujos/ES
Keywords: Ultrasound-Colour Doppler, Ultrasound, MR, Soft tissues / Skin,
Musculoskeletal system, Musculoskeletal soft tissue
DOI: 10.1594/ecr2013/C-1867
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Page 1 of 41
Learning objectives
• Review the current classification of soft tissue tumors, as well as many

other conditions that can present as palpable soft tissue lesions (tumor-like
lesions).
• Show ultrasound findings of these entities and their correlation with other
imaging techniques.
• Emphasize the benefits of ultrasound as an imaging technique of choice in
the initial study of patients presenting with a soft tissue mass.
Background
Patients are commonly referred for imaging to evaluate a soft-tissue mass in the trunk or
extremities. These lesions range from nonneoplastic conditions to benign and malignant
tumors. This study will review the current classification of soft tissue tumors and describe
multiple non-neoplastic entities that can present as soft tissue masses.
The World Health Organization (WHO) classification, established in 2002, includes more
than 80 tumors, divided into different groups as defined in table 1. Table 1 show the
abbreviated World Health Organization classification of soft-tissue tumors. In addition,
many tumor-like lesions (like inflammatory-infectious, traumatic, skin appendages or
other origin), are frequently encountered in practice.
Page 2 of 41
Fig. 1: Abbreviated WHO Classification of Soft-Tissue Tumors.
References: Radiología, Hospital San Juan de Dios del Aljarafe - Sevilla/ES
Imaging findings OR Procedure details
Page 3 of 41
TUMOR-LIKE LESIONS:
1. SYNOVIAL FLUID COLLECTIONS:
- SYNOVIAL CYSTS: Collections of synovial fluid representing a true herniation of

the synovial membrane through the joint capsule. Ultrasonography of nodular lesions
appear as well-defined borders, with anechoic content, or with fine echoes inside (fig. 2).
Sometimes identifying calcifications-ossifications (synovial osteochondromatosis).
Fig. 2: Synovial cyst.

- GANGLIA: Are lined by a capsule composed of flat spindle cells and do not have a
synovial lining. More frequent in wrists and hands. The sonographic appearance is a
nodular lesion with well defined borders, usually anechoic (fig. 3).
Page 4 of 41
Fig. 3: Ganglion cyst.
- TENOSYNOVITIS: Inflammation of a tendon and its synovial sheath. Thickening

and hypoechoic tendon wtih fluid in its tendon sheat is observed in ultrasound study,
sometimes in a way that is so evident as swelling or tumor of soft parts (fig. 4).
Page 5 of 41
Fig. 4: Tenosinovitis.
- BURSITIS: Inflammation of a bursa. Ultrasonography shows an anechoic collection of

well-defined edges, or with fine echoes inside, in usual location of a bursa.
2. INFLAMMATORY-INFECTIOUS LESIONS:
- PHLEGMON/ ABSCESS: Infectious changes in a different evolutionary phase.

Abscesses are focal, often well-defined collections of purulent fluid surrounded by a
prominently hypervascularized inflamade bordering tissue capsule, that can be observed
with color or power-doppler ultrasound (fig. 5). The inner content ranges from hypoechoic
to hyperechoic including internal septations and typical sedimenting debris with easily
provocable swirling of fluid within the mass after compression with the transducer.
Page 6 of 41
Fig. 5: Infectious tumor-like lesions.
- FOREIGN BODY REACTION-GRANULOMA: Inflammatory changes of the organism

in the presence of a foreign body. Ultrasound is an excellent imaging technique
for identifying foreign bodies, that are usually hyperechoic with hypoechoic and
hypervascularity periphery on Doppler assessment (foreign body reaction) (fig. 6).
Page 7 of 41
Fig. 6: Foreign body reaction.
3. TRAUMATIC INJURIES:
- HEMATOMA: hematomas of soft tissue may pose interpretative problems in the

differential diagnosis related to neoplastic masses (clinically important to assess direct or
indirect trauma history). They may appear as expansive inhomogeneous poorly bordered
masses in B-mode (fig. 7). There may be some reactive bordering vascularity (clearing
activity). Sometimes it is necessary to perform biopsy or histologic evaluation to rule out
malignancy.
Page 8 of 41
Fig. 7: Posttraumatic hematoma.
- POSTTRAUMATIC MORELL-LAVALÉE SEROMA: Serous or serohematic

posttraumatic subcutaneous collection located outside the muscle fascia. It is produced
by shearing of the tissues due to shear forces (eg typically in soft tissue trauma on asphalt
in road accidents). Typically these lesions are anechoic or hypoechoic, however internal
debris, including fat globules can give rise to echogenic foci or even fluid fluid levels. A
capsule of variable thickness may be seen (fig. 8).
Page 9 of 41
Fig. 8: Posttraumatic Morel-Lavallée seroma.
- MUSCLE HERNIA: Consists of a muscle focal herniation through a defect located in

the fascia that surrounds it. It most often occurs in the lower extremities, especially in
the anterior tibial compartment. The ultrasound allows diagnosis because of the dynamic
assessment of the palpable area asking patients affected muscle contraction (fig. 9).
Page 10 of 41
Fig. 9: Muscular hernia.
4. SKIN APPENDAGES MASSES:
- EPIDERMOID (EPIDERMAL INCLUISON) CYST: True epitheliallly lined cysts with

internal echoes resulting from the presence of keratin and a varying amount of lipid
containing debris. Sonography show a well-defined, echoic sharp, and thin outer
bordering, and a homogeneous or heterogeous ("linear") inner texture. No considerable
surrounding or internal vascularity is seen (fig. 10).
Page 11 of 41
Fig. 10: Epidermoid cyst.
5. ENDOMETRIOSIS:
Abnormal growth of functioning endometrial tissue outside its usual location. In the
presence of a soft tissue mass in area gynecological or obstetric surgical scar, varying
in size (with the hormonal changes of the patient) should think a focus of endometriosis.
Ultrasonography shown as hypoechoic soft tissue lesions with irregular borders and
variable internal vascularity (fig. 11).
Page 12 of 41
Fig. 11: Endometriosis.
6. VASCULAR LESIONS:
There are different types of vascular alterations that may present as a soft tissue tumor
in the exploration, as arterial elongation (usually in patients with hypertension), arterial
aneurysms and arterial or venous pseudoaneurysms (fig. 12).
Page 13 of 41
Fig. 12: Tumor-like vascular lesions.
7. ABDOMINAL WALL HERNIAS:
The herniations through defects in the abdominal wall may be presented as palpable
masses. It is important to assess the location and content. The most common hernias
that may present as clinically palpable masses are inguinal and periumbilical hernias.
Ultrasound is usually diagnostic. The ultrasonographic appearance depend of the hernial
content (fig. 13).
Page 14 of 41
Fig. 13: Hernia pathology.
SOFT-TISSUE TUMORS:
1. ADIPOCYTIC TUMORS:
The fatty tumors are the most common of mesenchymal tumors group (due to the
high incidence of lipomas). Lipomas are usually located in the subcutaneous tissue.
Lipomas are homogeneously hyperechoic masses with or withour capsule (no indicator
of malignancy), without areas of nodularity or thckened sepatations. No vascularization
are generally detected on doppler assessment (fig. 14).
Page 15 of 41
Fig. 14: Lipoma.
Lipomatosis of nerve is a proliferation of fat within a nerve, most commonly affecting

the median nerve (fig. 15).
Page 16 of 41
Fig. 15: Neural fibrolipoma.
Atypical lipomatous tumors/ well-differentiated liposarcomas (locally aggressive)

may resembe lipomas (over 75% of the tumor volume is fat). Ultrasonography shown
lipomatous tumor appearance, usually larger, more heterogeneous and with areas of
vascularization (fig. 16).
Page 17 of 41
Fig. 16: Well-differentiated liposarcoma.
The radiographic appearance of malignant liposarcomas will depend on the fat, myxoid
and cellular components, and vascular necrosis that may be present (sometimes no fatty
component is detected in imaging techniques) (fig. 17).
The major challenge from the radiological point of view is the distinction between well-
differentiated liposarcomas and lipomas. Findings for a diagnosis for well-differentiated
liposarcoma are:
- Growth and / or pain of the tumor

- Deep location
- Size larger than 10 cm

- Thick septations. nodular or cystic / necrotic component
- Hypervascularization
Page 18 of 41
Fig. 17: Myxoid liposarcoma.
2. FIBROBLASTIC/ MIOFIBROBLASTIC TUMORS
- NODULAR FASCIITIS: It is typical composed by well-deffined, ovoid or lobulated,

hypoechoic subcutaneous masses which may also affect deep muscle fasicas (fig. 18).
Page 19 of 41
Fig. 18: Nodular fasciitis.
- MYOSITIS OSSIFICANS TRAUMATICA (MOT): Benign proliferative process with

heterotopic ossification following soft tissue trauma. Sonographically show different
aspects depending on the time evolution. In the early stages can only exist
hypoechogenicity of injured muscle fibers, progressing toward nodular hyperechoic
(ossifying) areas, mainly in the periphery of the lesion. May also coexist hypervascularity
(fig. 19).
Page 20 of 41
Fig. 19: Myositis ossificans traumatica and calcifying panniculitis.
- ELASTOFIBROMA DORSI: Pseudo-tumoral lesion showing a typical location

(subscapularis) and radiographic appearance, caused by repeated microtrauma.
Ultrasonography shows a relatively ill-defined edges, with heterogeneous echotexture,
globally hyperechoic, with a fibrillar pattern (fig. 20).
Page 21 of 41
Fig. 20: Elastofibroma dorsi.
- MUSCULOSKELETAL FIBROMATOSIS: Group of proliferative lesions of soft tissue,

which can be superficial or deep fibromatosis. The most frequent superficial lesions are
plantar (Ledderhose disease) and palmar fibromatosis (Dupuytren's disease). The typical
nodules are hypoechoic, with often a little blurry margination but without calcifications or
any cystic components, affecting the palmar or plantar fascia (fig. 21). These lesions may
show hypervascularity in proliferative phase (symptomatic). The deep musculoskeletal
fibromatosis are commonly larger in size and may show a more aggressive and infiltrative
growth pattern.
Page 22 of 41
Fig. 21: Plantar fibromatosis.
- HEMANGIOPERICYTOMAS: Peripherally tumoral lesions, which most often affects

middle-aged adults with nonspecific radiographic appearance of heterogeneous
echotexture, with hypo and hyperechoic areas. May show cystic or hemorrhagic
component (fig. 22).
Page 23 of 41
Fig. 22: Hemangiopericytoma.
- FIBROSARCOMAS: Heterogeneous expansive lesions (hypo and hyperechoic areas),

may show foci of calcification or ossification, relatively hypovascular, sometimes with
pseudocapsule formation and tendency to invade adjacent structures (fig. 23).
Page 24 of 41
Fig. 23: Fibrosarcoma.
3. SO-CALLED FIBROHISTIOCYTIC TUMORS:
- GIANT CELL TUMOR OF THE TENDON SHEAT (localized nodular tenosynovitis):

Second most frequent tumor of the hand (after ganglions). It appears as a hypoechoic,
usually homogeneous lesionin contact with a tendon, slow growing and may produce
bone erosion. With Doppler study can be demonstrated internal or peripheral vasculature
(fig. 24).
Page 25 of 41
Fig. 24: Giant cell tumor of tendon sheat.
- PLEOMORPHIC MALIGNANT FIBROUS HISTIOCYTOMA (undifferentiated

pleomorphic sarcoma): Most tumors that in the past were considered malignant fibrous
histiocytoma are currently considered as fibrosarcomas (fig. 25).
Page 26 of 41
Fig. 25: Pleomorphic fibrous histiocytoma.
4. SMOOTH MUSCLE TUMORS:
ANGIOLEIOMYOMA: Benign tumor of smooth muscle, subcutaneous location, slow-

growing, well-defined borders, hypoechoic and usually shows moderate signs of
vascularization (fig. 26).
Page 27 of 41
Fig. 26: Angioleiomyoma.
5. PERICYTIC (PERIVASCULAR) TUMORS:
GLOMUS TUMOR: Usually located in acral areas (typical subungual location).

Typically they are painful to stimuli such as cold, pressure or temperature changes.
Ultrasonography shows a hypoechoic lesion, with significant Doppler vascularity in
Doppler color study (fig. 27).
Page 28 of 41
Fig. 27: Glomus tumor.
6. SKELETAL MUSCLE TUMORS:

Rhabdomyomas are rare tumors, which are divided between cardiac and extracardiac
rhabdomyomas. Rhabdomyosarcoma is radiologically indistinguishable from other
types of sarcomas.
7. VASCULAR TUMORS:
HEMANGIOMAS and VASCULAR MALFORMATIONS: Most frequent benign soft
tissue hamartomas. Ultrasonography usually present as ill-defined lesion, with markedly
heterogeneous echotexture, and sometimes contain internal areas pseudocystic and
phleboliths (which manifest as hyperechoic images with posterior acoustic shadowing).
They may have a cap hyperechoic (fat) in the periphery of the lesion. MRI is needed to
assess the full extent of the tumor extension (often greater than observed in ultrasound)
(fig. 28).
Page 29 of 41
Fig. 28: Hemangioma.
8. EXTRASKEKELETAL CHONDRO-OSSEOUS TUMORS:
Soft-tissue chondroma is the most frequent benign osteo-chondral tumor, and soft
tissue osteosarcoma and mesenchymal chondrosarcoma are the representation of
malignancy in this group. The ultrasonographic appearance will vary depending on its
bone matrix component, hemorrhage or necrosis (figs. 29, 30 and 31).
Page 30 of 41
Fig. 29: Osteosarcoma.
Page 31 of 41
Fig. 30: Extraskeletal osteosarcoma.
Page 32 of 41
Fig. 31: Mesenchimal chondrosarcoma.
9. PERIPHERAL NERVE SHEAT TUMORS (PNST):

PNST are classified separately as neurogenic tumors by the WHO and comprise benign
and malignant PNST.
- SCHWANNOMAS are benign tumors of the nerve sheath. Connection with a nerve
and the presence of tiny inner pseudocysts are patognomonic features (fig. 32). They
are usually well vascularized without exhibiting necrotic areas. In contrast, the so-called
"ancient schwannomas", presents large concentric cystic inner transformations.
Page 33 of 41
Fig. 32: Schwannoma.
- NEUROFIBROMAS: A neurofibroma is a circumscribed, spindle-shaped mass defined,

with a typically layered appareatance in axial scans ("target sign"). In contras to
schwannomas the vascularization is sparse. Multifocal neurofibromas plexiform and
multifocal variant may occur in neurofibromatosis type 1 (fig. 33).
Page 34 of 41
Fig. 33: Neurofibroma.
- MALIGNANT PERIPHERAL NERVE SHEAT TUMORS (MPNST) may show a

variable appearance, from well circumscribed to infiltrative masses. In most cases, very
heterogenic areas consisting of necrosis, hemorrhages, and calcifications are found.
Important vascularization are usually present (fig. 34).
Page 35 of 41
Fig. 34: Malignant peripheral nerve sheath tumor.
10. TUMORS OF UNCERTAIN DIFFERENTIATION:

This group includes tumors without a clear differentiation.
SYNOVIAL SARCOMA is the fourth most common type of soft tissue sarcomas.
The lesion does not commonly arise in intra-articular location, but usually occurs in
para-articular soft-tissue. Findings of a lobulated, highly vascularized soft-tissue mass,
particulary if cacificed (30%), in a paraarticular region, particularly in a lower limb of a
young patient, is verty suggestive of a synovial sarcoma (fig. 35).
Page 36 of 41
Fig. 35: Sinovial sarcoma.
11. LYMPHOMAS:
The subcutaneous tissue can be the primary settlement site of peripheral T-cell
lymphomas (Non-Hodgkin). The subcutaneous lymphoma T cells may present clinically
as a cellulitis or inflammatory changes. Ultrasound can show a significant increased
echogenicity and swelling of the fat lobes, with poor differentiation between the skin and
subcutaneous tissue (fig. 36).
Page 37 of 41
Fig. 36: Lymphoma.
METASTASIS:
Soft-tissue metastasis of carcinomas, sarcomas, or malignant melanomas are usually

predomininantly hypoechoic, poorly bordered, and inhomonegenous masses. Soft-tissue
metastasis often show significant hypervascularity (fig. 37).
Page 38 of 41
Fig. 37: Soft-tissue metastases.
Conclusion
Ultrasonography should be the imaging modality of choice in the initial evaluation of a

patient with soft tissue mass, for its many advantages (accessibility, cost, no ionizing
radiation, direct contact with the patient...).
It is important to know the different types of tumors and tumor-like can be presented as
"masses" of soft tissue, as well as the current classification, and the main sonographic,
radiological, even clinics features. It is also important to admit the limitations of ultrasound
(eg in large masses, deep location, ...), and the limitations of radiology (the impossibility
of label or characterize the tumor in many cases), to decide the proper attitude in each
individual case (need for histological study of uncertain nature or probably malignant
lesions).
Page 39 of 41
References
- Widmann G, Riedl A, Schoepf D, Glodny B, Peer S, Gruber H. State-of-the-art HR-

US imaging findings of the most frequent musculoskeletal soft-tissue tumors. Skeletal
Radiol. 2009 Jul;38(7):637-49.
- Wu JS, and Hochman MG. Soft-Tissue Tumors and Tumorlike Lesions: A Systematic
Imaging Approach. Radiology, November 1, 2009; 253(2): 297 - 316.
- Beggs I. Pictorial review: imaging of peripheral nerve tumours. Clin Radiol 1997; 52:8
-17.
- Kransdorf MJ. Benign soft-tissue tumors in a large referral population: distribution of

specific diagnoses by age, sex, and location. AJR Am J Roentgenol 1995;164:395-402.
- Murphey MD, Smith WS, Smith SE, Kransdorf MJ, Temple HT. Imaging of
musculoskeletal neurogenic tumors: radiologic- pathologic correlation. RadioGraphics
1999; 19:1253-1280.
- Banks KP. The target sign: extremity. Radiology 2005;234:899-900.
- Vilanova JC, Woertler K, Narvaez JA, et al. Soft-tissue tumors update: MR imaging
features according to the WHO classification. Eur Radiol 2007;17:125-138.
- Van Vliet M ,Kliffen M , Krestin GP et al. Soft tissue sarcomas at a glance: clinical,
histological, and MR imaging features of malignant extremity soft tissue tumors. Eur
Radiol (2009) 19: 1499-1511.
- Fletcher CDM, Unni KK, Mertens FE(eds) (2002)World Health Organization

Classification of tumors. Pathology and genetics of tumours of soft tissue and bone.
IARC, Lyon.
- Koh SH, Choe HS, Lee IJ, Park HR, Bae SH. Low-grade fibromyxoid sarcoma:
ultrasound and magnetic resonance findings in two cases. Skeletal Radiol 2005
34:550-554.
- De Schepper AM (ed) (2001) Imaging of soft tissue tumors, 2nd edn. Springer-
Verlag, Berlin.
- Murphey MD, Gross TM, Rosenthal HG. Musculoskeletal malignant fibrous

histiocytoma: radiologic-pathologic correlation. RadioGraphics 1994;14:807-26.
- Kransdorf MJ, Murphey MD. Radiologic evaluation of soft-tissue masses: a current

perspective. AJR Am J Roentgenol 2000; 175:575-587.
Page 40 of 41
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High-resolution ultrasound in the assessment of soft tissue

tumors and tumor-like lesions

Poster No.: C-1867

• Review the current classification of soft tissue tumors, as well as many

Imaging findings OR Procedure details

1. SYNOVIAL FLUID COLLECTIONS:

- SYNOVIAL CYSTS: Collections of synovial fluid representing a true herniation of

Fig. 2: Synovial cyst.

- TENOSYNOVITIS: Inflammation of a tendon and its synovial sheath. Thickening

- BURSITIS: Inflammation of a bursa. Ultrasonography shows an anechoic collection of

- PHLEGMON/ ABSCESS: Infectious changes in a different evolutionary phase.

- FOREIGN BODY REACTION-GRANULOMA: Inflammatory changes of the organism

- HEMATOMA: hematomas of soft tissue may pose interpretative problems in the

- POSTTRAUMATIC MORELL-LAVALÉE SEROMA: Serous or serohematic

- MUSCLE HERNIA: Consists of a muscle focal herniation through a defect located in

4. SKIN APPENDAGES MASSES:

- EPIDERMOID (EPIDERMAL INCLUISON) CYST: True epitheliallly lined cysts with

7. ABDOMINAL WALL HERNIAS:

Lipomatosis of nerve is a proliferation of fat within a nerve, most commonly affecting

Atypical lipomatous tumors/ well-differentiated liposarcomas (locally aggressive)

- Growth and / or pain of the tumor

- Size larger than 10 cm

2. FIBROBLASTIC/ MIOFIBROBLASTIC TUMORS

- NODULAR FASCIITIS: It is typical composed by well-deffined, ovoid or lobulated,

- MYOSITIS OSSIFICANS TRAUMATICA (MOT): Benign proliferative process with

- ELASTOFIBROMA DORSI: Pseudo-tumoral lesion showing a typical location

- MUSCULOSKELETAL FIBROMATOSIS: Group of proliferative lesions of soft tissue,

- HEMANGIOPERICYTOMAS: Peripherally tumoral lesions, which most often affects

- FIBROSARCOMAS: Heterogeneous expansive lesions (hypo and hyperechoic areas),

3. SO-CALLED FIBROHISTIOCYTIC TUMORS:

- GIANT CELL TUMOR OF THE TENDON SHEAT (localized nodular tenosynovitis):

- PLEOMORPHIC MALIGNANT FIBROUS HISTIOCYTOMA (undifferentiated

4. SMOOTH MUSCLE TUMORS:

ANGIOLEIOMYOMA: Benign tumor of smooth muscle, subcutaneous location, slow-

5. PERICYTIC (PERIVASCULAR) TUMORS:

GLOMUS TUMOR: Usually located in acral areas (typical subungual location).

6. SKELETAL MUSCLE TUMORS:

8. EXTRASKEKELETAL CHONDRO-OSSEOUS TUMORS:

9. PERIPHERAL NERVE SHEAT TUMORS (PNST):

- NEUROFIBROMAS: A neurofibroma is a circumscribed, spindle-shaped mass defined,

- MALIGNANT PERIPHERAL NERVE SHEAT TUMORS (MPNST) may show a

10. TUMORS OF UNCERTAIN DIFFERENTIATION:

Soft-tissue metastasis of carcinomas, sarcomas, or malignant melanomas are usually

Ultrasonography should be the imaging modality of choice in the initial evaluation of a

- Widmann G, Riedl A, Schoepf D, Glodny B, Peer S, Gruber H. State-of-the-art HR-

- Kransdorf MJ. Benign soft-tissue tumors in a large referral population: distribution of

- Banks KP. The target sign: extremity. Radiology 2005;234:899-900.

- Fletcher CDM, Unni KK, Mertens FE(eds) (2002)World Health Organization

- Murphey MD, Gross TM, Rosenthal HG. Musculoskeletal malignant fibrous

- Kransdorf MJ, Murphey MD. Radiologic evaluation of soft-tissue masses: a current

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