Figure 1
US
Oval lesion, which is partially hypoechoic and hyperechoic, localised in the trapezius muscle. The signal is irregular and compatible with solid lesion.
Unusual location for a leiomyosarcoma: preoperative features, surgery and follow up.
SectionMusculoskeletal system
Case TypeClinical Cases
AuthorsRuschi F, Parchi P, Paolicchi A, Scandiffio R, Pascale R, Barattini M, Caramella D, Bartolozzi C
Connected authors
36 years, female
Clinical History
The patient, a woman affected by scleroderma, presented with pain localised in the shoulder region, lasting for about 1 month and increased by movement.
Imaging Findings
The patient, a 36-year-old woman affected by scleroderma diagnosed some years before, presented with pain localised in the shoulder region, lasting for about one month and exacerbated by movement. There was no history of direct trauma. A sonography was performed and showed an oval and solid lesion irregular signal (partially ipoechoic and iperechoic) and localised in the context of trapezius muscle. A contrast-enhanced MRI study was useful in order to define the nature of this lesion: SE T1 before intravascular contrast medium confirmed the presence of a well circumscript soft tissue mass in the trapezium, which was hypointense and homogeneous. After intravenous administration of gadolinium strong enhancement was demonstrated.
The lesion was surgically resected: it was a well circumscript tumor (correlating with MRI results). Biopsy revealed the presence of a leiomyosarcoma.
After one month a CT total body examination was performed in order to stage the cancer: it showed the absence of significant lymphadenopathy in the neck, abdomen and pelvis. No lung metastasis were detected.
CT showed both lungs having a ground glass feature especially in the middle and lower fields, because of scleroderma.
After one month a follow up contrast-enhanced MRI examination of the right shoulder showed the presence of the scar (related to surgery). There was an irregular area of oedema, exhibiting enhancement in the late phase. No persistence or recurrence of disease was visible.
The lesion was surgically resected: it was a well circumscript tumor (correlating with MRI results). Biopsy revealed the presence of a leiomyosarcoma.
After one month a CT total body examination was performed in order to stage the cancer: it showed the absence of significant lymphadenopathy in the neck, abdomen and pelvis. No lung metastasis were detected.
CT showed both lungs having a ground glass feature especially in the middle and lower fields, because of scleroderma.
After one month a follow up contrast-enhanced MRI examination of the right shoulder showed the presence of the scar (related to surgery). There was an irregular area of oedema, exhibiting enhancement in the late phase. No persistence or recurrence of disease was visible.
Discussion
Superficial soft-tissue masses are common in clinical practice. The imaging features of many superficial soft-tissue lesions may be nonspecific. In such cases, the use of a systematic approach can help narrow the differential diagnosis.
Superficial soft-tissue masses may be classified as: mesenchymal tumors, skin appendage lesions, metastatic tumors, other tumors and tumorlike lesions and inflammatory lesions.
It is most useful to consider two patient age groups: adults and children-adolescents. Moreover, the location of a lesion within the superficial tissue is best described as cutaneous, subcutaneous or fascial, overlying the muscle or deep tissue.
After a differential diagnosis is established on the basis of the patient’s age and the location of the lesion, it may be further ordered by considering that information in combination with the imaging characteristics.
Soft tissue sarcomas (STS) account for approximately 1% of malignant tumours. There are more than 50 subtypes.
Management of these lesions should begin with a clinical examination followed by MRI. Leiomyosarcomas usually present as nonspecific soft tissue masses with low-intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Post-gadolinium T1-weighted images show moderate enhancement, except for the areas of central necrosis or cystic change, which are common. Less frequently there may be regions of haemorrhage, appearing as areas of increased signal intensity on T1-WI. Areas of calcification showing low signal intensity on T1- and T2-WI may occasionally be seen.
LMS shows a high primary growth-rate and a rate of local recurrence of 40 to 60%. Distant metastases affect commonly the lungs, bones, central nervous system and liver in 30 to 60% of patients and they are best studied by CT. Metastases can also be studied with FDG-PET, which can distinguish benign lesions from malignant lesions with a sensitivity of 92% and a specificity of 100%.
Differential diagnosis includes myofibrosarcoma, fibrosarcoma, rhabdomyosarcoma, metastasis and it can be made only after detailed histopathologic analysis.
Treatment is dictated by stage, location, size and patient age. The primary modality of therapy is surgery: a wide excision with 3-5 cm lateral margins is recommended. Lymph node metastases account for 10 to 15% of cases. Radiotherapy has been used as an adjuvant therapy to minimise the incidence of local recurrence.
Superficial soft-tissue masses may be classified as: mesenchymal tumors, skin appendage lesions, metastatic tumors, other tumors and tumorlike lesions and inflammatory lesions.
It is most useful to consider two patient age groups: adults and children-adolescents. Moreover, the location of a lesion within the superficial tissue is best described as cutaneous, subcutaneous or fascial, overlying the muscle or deep tissue.
After a differential diagnosis is established on the basis of the patient’s age and the location of the lesion, it may be further ordered by considering that information in combination with the imaging characteristics.
Soft tissue sarcomas (STS) account for approximately 1% of malignant tumours. There are more than 50 subtypes.
Management of these lesions should begin with a clinical examination followed by MRI. Leiomyosarcomas usually present as nonspecific soft tissue masses with low-intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Post-gadolinium T1-weighted images show moderate enhancement, except for the areas of central necrosis or cystic change, which are common. Less frequently there may be regions of haemorrhage, appearing as areas of increased signal intensity on T1-WI. Areas of calcification showing low signal intensity on T1- and T2-WI may occasionally be seen.
LMS shows a high primary growth-rate and a rate of local recurrence of 40 to 60%. Distant metastases affect commonly the lungs, bones, central nervous system and liver in 30 to 60% of patients and they are best studied by CT. Metastases can also be studied with FDG-PET, which can distinguish benign lesions from malignant lesions with a sensitivity of 92% and a specificity of 100%.
Differential diagnosis includes myofibrosarcoma, fibrosarcoma, rhabdomyosarcoma, metastasis and it can be made only after detailed histopathologic analysis.
Treatment is dictated by stage, location, size and patient age. The primary modality of therapy is surgery: a wide excision with 3-5 cm lateral margins is recommended. Lymph node metastases account for 10 to 15% of cases. Radiotherapy has been used as an adjuvant therapy to minimise the incidence of local recurrence.
Differential Diagnosis List
Leiomyosarcoma localized in the context of the trapezius muscle.
Final Diagnosis
Leiomyosarcoma localized in the context of the trapezius muscle.
References
[1] van Vliet M, Kliffen M, Krestin GP, van Dijke CF (2009) Soft tissue sarcomas at a glance: clinical,histological and MR imaging features of malignant extremity soft tissue tumors. Eur Radiol 19: 14991511 (PMID: 19266204)
[2] Stacy GS, Nair L (2007) Magnetic resonance imaging features of extremity sarcomas of uncertain differentiation. Clin Radiol 62:959-60 (PMID: 17765459)
[3] Varma DG (2000) Imaging of soft-tissue sarcomas. Curr Oncol Rep 2:487-90 (PMID: 11122882)
[4] Beaman FD, Kransdorf MJ, Andrews TR, Murphey MD, Arcara LK, Keeling JH. (2007) Superficial soft-tissue masses: analysis, diagnosis, and differential considerations. Radiographics 27(2):509-23 (PMID: 17374866)
Case information
| URL: | https://eurorad.org/case/8377 |
| DOI: | 10.1594/EURORAD/CASE.8377 |
| ISSN: | 1563-4086 |
Figure 2
MRI
SE T1 before intravascular contrast medium: oval lesion which is hypointense and localised in the context of trapezius muscle. There is no infiltration of adjacent tissues (regular and sharp outline).
After intravenous administration of gadolinium SE T1 shows clear enhancement of the lesion.
FSE T2: oval hyperintense lesion, which is localised in the context of trapezius muscle. The tumor is well circumscript.
Figure 3
CT
Both lungs have a ground glass feature especially in the lateral and posterior part of the subpleural parenchyma, because of scleroderma.
No lung metastasis were detected.
US
Oval lesion, which is partially hypoechoic and hyperechoic, localised in the trapezius muscle. The signal is irregular and compatible with solid lesion.
MRI
SE T1 before intravascular contrast medium: oval lesion which is hypointense and localised in the context of trapezius muscle. There is no infiltration of adjacent tissues (regular and sharp outline).
After intravenous administration of gadolinium SE T1 shows clear enhancement of the lesion.
FSE T2: oval hyperintense lesion, which is localised in the context of trapezius muscle. The tumor is well circumscript.
CT
Both lungs have a ground glass feature especially in the lateral and posterior part of the subpleural parenchyma, because of scleroderma.
No lung metastasis were detected.
