Textbook Reading of Radiology and Imaging

DAVID SUTTON 7th edition, Volume 2, page 1441-1442, Chapter 45 : The Soft Tissue

TUMOURS

Presented by Fahroni Erlianur

Consultant : dr. Amri Wicaksono Pribadi,
Sp.Rad
Section 5 Skeletal System
Chapter 45: The Soft Tissue
PLAIN FILMS
Calcification
• Arteries, veins, nerves, lymph nodes,tendons
• Parasites
• Metabolic
• Hematomas
• Soft tissue necrosis
• Calcinosis circumscripta
• Calcinosis interstitialis
universalis/dermatomyositis
• Tumoral calcinosis
• Pseudoxanthoma elasticum
Ossification
Tumours
CONTENT
INTRODUCTION
01 (Definition, etiology, epidemiology, clinical
manifestation)

02 PATHOPHYSIOLOGY
RADIOLOGICAL
03 MODALITIES
DIFFERENTIAL
04 DIAGNOSIS
05 MIND MAPS

06 QUIZ
 01
INTRODUCTION
DEFINITION
• Soft Tissue Tumours, Neoplastic conditions arising in
extraskeletal mesodermal tissues ; fibrous tissue, smooth
muscle, skeletal muscle, adipose tissue, blood & lymphatic
vessels, peripheral nerves.
• A classification has been developed by Enzinger using the
principle of similarity of histologic appearance to normal
tissues (Table 1).

(Weiss et al., 2019; Shidam et

al., 2020)
01
INTRODUCTION

(Weiss et al., 2019)

 01
INTRODUCTION
ETIOLOGY

• Radiation
• Genetic Condition
• Environmental Carcinogens
• Infection
• Trauma
• Chronic Lymphedema

(Shidam et al., 2020)

 01
INTRODUCTION
EPIDEMIOLOGY

• Benign soft-tissue tumors occur at least 10 times more

frequently than malignant ones.
• Incidence of soft-tissue sarcomas ranges from 15 to 35
per 1 million population, increase with age.
• Slightly higher in men than in women.

(Shidam et al., 2020))

 01
INTRODUCTION
CLINICAL MANIFESTATION
• Palpable mass in subcutaneous or deeper tissue
• Depending on anatomic location, it may cause pain and
neurologic symptom
• Rapid rate increase of size, extremity masses, fatigue.
Suspicion that the lesion is malignant.

Weiss et al., 2019; Shidam et

al., 2020)
02 PATHOPHYSIOLOGY

(Tamniselvan G., 2015)

 03 Radiology Modalities
Suited as initial triage imaging
modality such as dens, size, shape,
number, vascularity, location and
anatomical relationship.
Ultrasound (USG)
1 2
Computed Tomography (CT)
3 4
Most effective modality for detailed
evalution of area with complex osseous
anatomy (eg, chest wall). Useful in
patiens with contraindications to MRI.
Frequently non-contributory, but
evaluate wheter the soft tissue
tumor is actually originating from.
Plain X-Ray
Magnetic Resonance Imaging (MRI)
Modality of choice, with the best soft tissue contrast,
provide multiplanar capability, vascular structures,
and vascular can also be more easily recognized.
(Dianal et al., 2015 ;
Sutton D., 2002)
04 Differential Diagnosis

Benign Malign
Common Case • Lipoma • Sarcoma
• Hemangioma • Metastatic Carcinoma
• Fibroma

Clinical • Palpable Mass • Palpable Mass

• Painless • Accelerated onset of disease
Manifestasion • Slow Growth • Pain & swelling of affected area
• Localized • Systemic features (Fever, anemia,
weight loss)
• Usually penetrated to surrounding
organs

(Mayerson J et.al 2015)

 Lipoma
• Lipomas are benign tumors composed of mature adipocytes. They are the
most common soft tissue tumor, seen in ~2% of the population.
• Typically lipomas are subcutaneous in location and present in adulthood as a
soft painless mass in the trunk or proximal extremities. They are likely to have
been present for many years and may change size with weight fluctuation.

(O’donnel P., 2016)

 Lipoma (Plain X-Ray)
• In plain radiography large lipoma are visible as areas of relative lucency
(compared with soft tissues), but small lesions are not visible.

Figure 1. AP Radiograph shows an

ovoid lucent mass (arrows)
projected over the lateral aspect of
the forearm

(O’donnel P., 2016)

 Lipoma (USG)
• Light pressure with the ultrasound probe shows the lessions are
compressible, may appear encapsulated athough many lipomas appear to
blend with the surrounding tissue without evidence of a capsule.

Figure 2. US image shows an elliptical

mass (arrows), lower in reflectivity than
ajacent muscle (M) but more reflectivity
than subcutaneous fat (F)

(O’donnel P., 2016)

 Lipoma (MRI)
• MR is the modality of choice for imaging lipomas, better able to demonstrate the
surrounding anatomy.
• T1 : High signal, saturates on fat-saturated sequences, no or minimal enhancement
• T2 : High signal on FSE t2, saturated on fat-saturated sequences

Figure 3. T1-weighted images reveal an

ovoid mass (arrows) of predominantly
hyperintense signal intensity (similar to
fat) within the right quadratus femoris
muscle

(O’donnel P., 2016)

 Hemangioma
• Hemangioma of Soft Tissue is a benign vascular neoplasm that may be
located in a cutaneous, subcutaneous, or intramuscular location
• Most commonly diagnosed soft tissue tumor in children, women more
commonly affected than men.

(Olsen K., et.al., 2016)

 Hemangioma (Plain X-Ray)
• In plain radiography show a soft tissue mass containing multiple phleboliths
(especially in cavernous hemangiomas)

Figure 4. Soft tissue mass (white

arrows) which contains numerous
spherical calcifications
characteristic of phleboliths (red
oval). The combinations is
characteristic of a hemangioma
soft tissue)

(Olsen K., et.al., 2016)

 Hemangioma (USG)
• In US tpypically seen as an ill-defined or well-defined hypoechoic mass of
heterogeneous echotexture with mitple cystic space within.

Figure 5. Subcutanoeous soft

tissue mass with cystic
spaces and tiny calcifications
proved the lesion to be a
hemangioma

(Olsen K., et.al., 2016)

 Hemangioma (MRI)
• On MRI, T1 weighted images showed that most of the lesions were isointense or isohyperintense, as
compared with muscle tissue; however, on T2 weighted images all lesions appeared as hyperintense
with a low singal intensity foci or fluid-fluid level.

Figure 6. Axial T2 weighted

MR image of the knee shows
a high signal intensity mass
with low signal intensity foci
(arrow)

(Olsen K., et.al., 2016)

 Fibroma

• Composed of fibrous or connective tissue. They

can grow in all organs, arising
from mesenchyme tissue and also vary in their
behavior, ranging from indolent/benign lesions to
malignant/metastic.

(Omor Y., et.al., 2015)

 Fibroma (USG)
• Most fibromas are round, oval or lobulated solid tumors, firm single thickening,

Figure 7. Typical round iregular

fibroma with significant
hyperemia in doppler

(Omor Y., et.al., 2015)

 Fibroma (MRI)
• On MR Imaging, fibroma appears as a well-defined nodule, has low signal intensity on T1-
weighted and low to-intermediate signal intensity on T2-weighted sequences

Figure 8. Sagittal T1-weighted

image demonstrated a nodular
soft-tissue masse in the distal
plantar fascia, which
are hypointense to muscle.

(Omor Y., et.al., 2015)

 SARCOMA
A

• A type of malignant tumor that arises from

transformed celss of mesenchymal soft
tissues of the body, including cartilage, fat,
muscle, blood vessels, fibrous tissue, or other
connective or supportive tissue.
• Imaging of soft tissue sarcomas requires a
multimodality approach, with no single
imaging modality being ideal for every tumor.

(Weiss et al., 2019)

 SARCOMA
A
Plain X-Ray

• Frequently non-contributory, but evaluate wheter

the soft tissue tumor is actually originating from.

• Figure 10. A 66-year-old woman with synovial

sarcoma. (A) Plain radiograph of the hand shows a
soft tissue mass centered on the thenar eminence
of the left hand with destruction of the first
metacarpal bone and areas of calcification within.

(Jagannathan et al., 2019)

 SARCOMA
A
USG

• The US was an effective triage tools in the

investigation of soft tissue lesion.
• Figure 9. Transverse ultrasound image of
the upper arm in a 65-year-old lady
presenting with a soft tissue mass. A
hypoechoic central portion is seen
surrounded by a solid rim with internal
vascularity.
• The lesion was indeterminate on imaging
but was found to be a squamous cell
carcinoma on histology

(Rowbotham et al., 2012)

 SARCOMA
A
CT SCAN

• On CT images, these lesions are well-

circumscribed, multinodular, or infiltrating
masses of soft-tissue

• Figure 11. Contrast-enhanced CT images

show mostly homogeneous enhancement
of a well-circumscribed soft-tissue mass
(straight arrow) invading the left
anterolateral abdominal wall and
obliterating the left external iliac vein.

(Rowbotham et al., 2012)

 SARCOMA
A
MRI

• The most important role of MRI is in

defining the extent of a lesion and its
relation to adjacent anatomic structures.

• Figure 12. A 46-year-old female with a

poorly differentiated adult fibrosarcoma. (a,
b) Sagittal T1WI and T2WI exhibited a
lobulated long T1 and mixed T2 signal
mass in the right plantar deep fascia, with
band-like areas of long T1 and short T2
signal (black arrows in (a) and (b))
indicating tumor fibrous septa.

(Wang H. et al., 2012)

 SOFT TISSUE CARCINOMA
METASTASE
A

• In contrast to bone metastases, soft tissue

metastases from carcinoma are rare and can
be the source of diagnostic confusion both
clinically and radiology, they are usually
misdiagnosed as soft tissue sarcoma.
• The distinction between a soft tissue
metastasis and primary soft tissue tumor or
inflammation is important, because the
treatment and prognosis are significantly
different
Copyrights © 2018 The Korean Society of
Radiology

(Watnough P., 2018 ; Park S., et al., 2018)

 SOFT TISSUE CARCINOMA
METASTASE
A
USG

• Sonographic provides a safe, rapid, and

accurate method for localizing superficial soft
tissue masses.

Figure 13. Intramuscular metastasis from choroid

melanoma. (a) Gray-scale US reveal a small solid
homogeneously hypoechoic nodule with spiculated
margins in the subcutaneous tissue of the abdominal
wall

(Park S., et al., 2018)

 SOFT TISSUE CARCINOMA
METASTASE
A
CT Scan

• CT is not an ideal method for characterization of

soft tissue metastases. Furthermore, soft tissue
metastases cannot be reliably distinguished from
the primary soft tissue sarcoma.

Figure 14. Intramuscular metastasis from choroid

melanoma. (a) Gray-scale US reveal a small solid
homogeneously hypoechoic nodule with spiculated
margins in the subcutaneous tissue of the abdominal
wall

(Park S., et al., 2018)

 SOFT TISSUE CARCINOMA
METASTASE
A
MRI

• MR imaging is the preferred technique for muscle

and soft tissue assessment, even though MRI
appearances of soft tissue metastasis are not
specific.
• Administration of contrast medium, most muscle
metastases show marked heterogeneous
enhancement related to tumor necrosis In addition,
extensive peritumoral enhancement has been
reported as one of the characteristic features of
intramuscular metastasis.

Figure 15. (b) Axial fat-suppressed (FS) T1-weighted

gadolinium-enhanced image shows well enhancing
mass in left psoas including central necrosis
(Park S., et al., 2018)
06 QUIZ
A 54 years men refers to Hospital after have a chronic
pain at right thigh. Physical examination obtained soft
tissue mass at right thigh, deeper than subcutaneous
tissue, irregular, swelling, and pain. USG at lesion
Infographic
performed Style well-defined ovoid lesion is
on the patient,
seen in the region of interest. Size: 7 x 7 x 5 cm.
What an imaging modalities should be done next ?

A. Plain X-Ray
B. MRI
C. CT Scan
D. PET/CT
TERIMA KASIH
Mohon Asupan
 REFERENCES

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