Role of ultrasound and color Doppler in evaluation

of musculoskeletal soft tissue masses

Essay

Submitted for partial fulfillment of Master Degree in radiodiagnosis

By Amr Osman Osman

M.B.B.Ch

Tanta university

Supervisors Dr.Ahmed Mohamed Wafaie

Assistant Professor of radiology

Cairo university

Dr. Nevien Ezzat El Liethy

Lecturer of radiology

Cairo university

Faculty of medicine

Cairo university

2012

Q

V

Acknowledgment

I

Acknowledgment

First and foremost I feel always indepted to god the most kind and the most

merciful .

I would like to express my sincere thanks and deep gratitude to professor

Dr. Ahmed Mohamed Wafaie Assistant Professor of diagnostic radiology,

Cairo university , for his help , guidance , unlimited cooperation , constructive

criticism and deep support .

My special thanks and deep gratitude to professor Dr. Nevien Ezzat El

Liethy Professor of diagnostic radiology, Cairo university, for his sincere help and

guidance to bring this work to reality.

Finally, I would like to express my deep gratitude to all my family

members especially my parents for their unwavering support and love and their

ability to instill within me a thirst for knowledge without which this effort would

not be possible., my wife (my much better half, a fact that anybody who knows me

will thoroughly agree with) for her unlimited cooperation, patience and deep

support. They provide my foundation and strength through their love and support.

List of content

II

List of contents

Title Pages

Acknowledgement I

List of content II

List of abbreviations III

List of Tables & charts IV

List of figures V-VII

Abstract VIII

Introduction 1-3

Aim of the work 4-5

Technique and sonographic anatomy of the musculoskeletal

system 6-21

Pathology of soft tissue tumor of the musculoskeletal system 22-29

Ultrasound and color Doppler appearance of most common

musculoskeletal soft tissue tumors:

I. Subcutaneous.

II. Inter and intramuscular.

III. Interarticular/juxta-articular.

IV. Tumor like masses.

30 – 51

52 – 73

74 – 87

88 – 98

Cases demonstration 99-108

Summary & conclusion 109-113

References 114-118

Arabic Summary 119 – 121

List of abbreviations

III

List of abbreviations:

Abbreviation

US Ultrasound

RI resistive index

SD standard deviation

CD Color Doppler

HRUS High resolution ultrasound

CDUS Color Doppler ultrasound

PDUS Power Doppler US

GCTTS Giant cell tumor of tendon sheath

DFSP Dermato-fibrosarcoma protuberance

MHZ Mega hertz

CT Computerized tomography

NF1 Neurofibromatosis type 1

MRI Magnetic resonance images

List of tables and charts

IV

List of tables and charts

Pages Table 1 : Locations of inflamed bursae evaluated by

Ultrasound. 84

Chart 1: Simple algorithm for worrying and un

worrying features for soft tissue lump

diagnosis.

112

Chart 2: An algorithm for investigating a patient

with soft tissue tumor. 114

List of figures

V

List of Figures

Figure Title Page

Figure 1,2 &3 : Commonly used ultrasound transducers in musculoskeletal ultrasound. 8

Figure 4: Color Doppler showing a large serpiginous feeding vessel. 10

Figure 5: Simple Doppler ultrasound instruments 11

Figure 6&7: The angle of insonation changes. 11

Figure 8: Normal skin and subcutaneous tissu photography and US 14

Figure 9: Subcutaneous veins and nerves diagram and US 15

Figure 10: Intramuscular aponeuroses & perimysium 16-17

Figure 12 : Normal quadriceps muscle (A) Longitudinal (B) Panoramic veiw 17

Figure 13: Normal nerve echotexture. 19

Figure 14: cuboid bone cartilage and bone by US. 23

Figure 15&16: US appearance of normal bone surface echotexture. 20

Figure 17-20: Hemangioma of the elbow , foot , thigh , leg , subcutaneous hemangioma 32-33

Figure 21: Subcutaneous hemangioma of the leg, 34

Figure 22: Cavernous hemangioma of the foot . 34

Figure 23: Intramuscular hemangioma of thelower extremity.photgraphy 35

Figure 24: Cystic lymphangioma (A) Grayscale ultrasonography (B) Color Doppler

ultrasonography. 36

Figure 25: Glomus tumor in index finger. (A) Grayscale ultrasonography (B) Color

Doppler ultrasonography 36

Figure 26: Dermatofibrosarcoma over the left abdominal wall (A&B) Grayscale

ultrasonography (C) CDUS (D): Photograph 37

Figure 27: Dermatofibrosarcoma protuberans of the abdominal wall (A), extended

view long axis (B), Doppler examination 38

Figure 28: Granuloma annulare focused ultrasound over the dorsum of the foot . 38

Figure 29: Leiomyosarcoma of the upper thigh mass A: Ultrasound. B: Color

Doppler 40

Figure 30-32: Superficial (subcutaneous) lipoma over the abdominal wall, the buttock,

left medial arm (grayscale ultrasonography) 41-42

Figure 33: lymphoma cell infiltration to the subcutaneous fat lobule of the right

proximal tibial region (A) Grayscale ultrasonography (B) CDUS . 43

Figure 34: Infantile fibrosarcoma of the forearm. A: Radiograph. (B) Grayscale

ultrasonography (C) CDUS 44

Figure 35: Malignant fibrohistiocytoma in right lateral thigh. (A) Longitudinal

ultrasound section (B) Color Doppler ultrasonography. 45

Figure 36: Fibrosarcoma in the upper leg. (A) Grayscale ultrasonography (B) CDUS

. 45

Figure 37: Low-grade sarcoma posterolateral thigh. (A) Grayscale ultrasonography

(B) CDUS . 46

Figure 38: Loco-regional spread of malignant cutaneous melanoma. 46

Figure 39: Subcutaneous metastasis of the abdominal wall CDUS . 47

Figure 40: metastasis from thyroid carcinoma in the left pelvic region with iliac bone

destruction (A) Grayscale ultrasonography (B) CDUS . 47

Figure 41: Subcutaneous metastasis of the thigh , Grayscale ultrasonography 48

Figure 42: Myxoma. in the plane between the rectus femoris and vastus intermedius

muscles (extended field of veiw) 49

List of figures

VI

Figure 43: Nodular fasciitis in the wrist & upper arm , Grayscale ultrasonography . 49

Figure 44-45: Epidermoid cyst. , Grayscale ultrasonography 50- 51

Figure 46: Fibroma on back. (A) Grayscale ultrasonography (B) CDUS . 51

Figure 47- 49 : Liposarcoma on left elbow &,the thigh. Grayscale ultrasonography- MRI

– intraoperative view - extended field of view 53-54

Figure 50: Palmar fibromatosis. of the third finger , Grayscale ultrasonography 57

Figure 51: Superficial fibromatosis in right thigh. (A) Grayscale ultrasonography (B)

Color Doppler 57

Figure 52: Plantar fibromatosis. of the plantar aspect of the foot Grayscale

ultrasonography 58

Figure 53: Calcifying Aponeurotic Fibroma A. High-resolution US of the phalanx (A)

Grayscale ultrasonography (B) Color Doppler 59

Figure 54: Fibromatosis colli of sternocleudomastoid muscle , Grayscale

ultrasonography 60

Figure 55: Fibrous Hamartoma of Infancy: A.Grayscale ultrasonography B. color

Doppler image. C. Non-enhanced CT scan. D. Sagittal reconstructed

contrast enhanced CT

62

Figure 56-57: Desmoid. Tumor (A) Grayscale ultrasonography (B) Color Doppler 63

Figure 58-59: Stump neuromas , Grayscale ultrasonography & Color Doppler 64-65

Figure 60: Third web space Morton’s neuroma. (A) Grayscale ultrasonography (B)

Color Doppler 65

Figure 61: Schwannoma of the median nerve Grayscale ultrasonography. 66

Figure 62: Neurofibroma in left medial arm. (A) Grayscale ultrasonography (B)

Color Doppler 67

Figure 63: Neurinoma of the leg. (A) Color Doppler (B). 3D CT reconstruction. 67

Figure 64: Benign nerve sheath tumor. (A) Grayscale ultrasonography (B) Color

Doppler 67

Figure 65: Malignant schwannoma of the forearm.,Grayscale ultrasonography 68

Figure 66: Plexiform neurofibroma , Grayscale ultrasonography 69

Figure 67-68: Intramuscular hemangioma of the lower extremity. (A) Grayscale

ultrasonography (B) Color Doppler 70

Figure 69-70: intermuscular lipoma , Grayscale ultrasonography , extended field of

veiw 71-72

Figure 71: rhabdomyosarcoma in the right thigh, Grayscale ultrasonography &

Color Doppler. 73

Figure 72-73: Lipoma arborescens of the knee: Microscopic and gross features, &

Grayscale ultrasonography 74-75

Figure 74: Pigmented villonodular synovitis over her right lower leg(A) Grayscale

ultrasonography (B) Color Doppler 76

Figure 75-76: Giant cell tumor of the tendon sheath in right thumb. (A) Grayscale

ultrasonography (B) Color Doppler 77

Figure 77: A–C. Giant cell tumor of the tendon sheath. (A) Grayscale

ultrasonography (B) Color Doppler.(C) Corresponding anteroposterior

standard radiograph.

78

Figure 78: A–d. Synovial chondromatosis. A Plain radiograph of the index finger. B

Grayscale ultrasonography. C Axial CT imaging. D Surgical specimen 79

Figure 79: a–d. Intra-articular bodies: spectrum of US appearances.- MRI

correlation 80

Figure 80-81: Baker’s cyst., Grayscale ultrasonography. 81

List of figures

VII

Figure 82-83: Iliopectineal and olecranon bursitis (A) Grayscale ultrasonography (B)

Color Doppler 82-83

Figure 84: a–f. Synovial hemangioma. A,B,C Grayscale ultrasonography & Color

Doppler over the suprapatellar region D Sagittal T2-weighted and E fat-

suppressed postcontrast T1-weighted MR imaging F Lateral radiograph

84

Figure 85-86: Synovial sarcoma of theknee and foot. Grayscale ultrasonography ,Color

Doppler and MRI image correlation 85

Figure 87: Volar wrist ganglion cyst. (A) Grayscale ultrasonography (B) Color

Doppler 86

Figure 88: Ganglion of the dorsal wrist Grayscale ultrasonography 87

Figure 89: Atypical digital ganglion in the thumb (A) Grayscale ultrasonography (B)

Color Doppler 87

Figure 90: Rectus femoris muscle tear. , Grayscale ultrasonography 88

Figure 91: Muscle hernia. a Photograph showing the examination technique for

detecting muscle hernias. b,c Schematic drawings illustrate the

mechanism of hernia. d–g Grayscale ultrasonography

90

Figure 92: Muscle hernia with a defect in the muscle fascia 91

Figure 93: Pseudoaneurysm (A) Grayscale ultrasonography (B) Color Doppler 92

Figure 94: Acute Vastus intermedius intramuscular ill-defined muscle hematoma ,

Grayscale ultrasonography 92

Figure 95: Intramuscular hematoma of the leg in various stages. (A) Grayscale

ultrasonography (B) Color Doppler (C) liquefied hematoma. 93

Figure 96-98: Muscle abscess.,Grayscale ultrasonography & Color Doppler 94-95

Figure 99: Idiopathic myositis with torticollis (A) Grayscale ultrasonography (B)

Color Doppler 96

Figure 100-101: Foreign body in right palm and in the superficial tissues of the thigh

Grayscale ultrasonography & Color Doppler 96-97

Figure 102: Myositis ossificans in left anterior thigh. 97

Figure 103: Tumoral calcinosis on shoulder , Grayscale ultrasonography & Color

Doppler 98

Abstract VIII

ABSTRACT

Musculoskeletal sonography is a rapidly growing technique that is gaining popularity for the evaluation and treatment of joint and soft tissue diseases . It can be intimidating due to the vast array of anatomy that is present and the different techniques and dynamic maneuvers required for a complete study. It is reliable, expedient and readily accessible alternative to other more costly techniques such as MR imaging.

In the detection of musculo-skeletal masses especially soft tissue masses , ultrasonography is a readily available , inexpensive and non invasive modality,color Doppler can be also used in assessment of lesion vascularity and detection of neurovascular bundle involvement.

Key word:MR- musculoskeletal- ultrasound- radiodiagnosis

Introduction

1

INTRODUCTION

Introduction

2

Introduction

Soft tissue masses in the extremities and trunk are common

presentations to physicians and surgeons. These growths range from benign

neoplasms and cystic structures based in the epidermis and dermis to

malignant neoplasms arising within the structures below the deep fascia.

(Frassica et al . , 1996).

There are a number of useful applications and advantages of

diagnostic ultrasound in the assessment of musculoskeletal pathology.

Ultrasonography (U/S) may be used to assess superficial tendons and

ligaments that traverse a joint. It can demonstrate the presence and

characteristics of joint effusions, bursae, or cysts, and it also can detect loose

bodies in joints. The advantages lie in the cost-efficiency, shorter

examination time, (Kelvin Chew etal . , 2008 )

Ultrasound is generally unaffected by metallic artifacts (eg, metatarsal

plate in the foot, suture anchors) and delivers no radiation to the patient or

the user, an important consideration when evaluating females of child-

bearing age. Unlike radiographs, CT, and MRI, ultrasound can be readily

used to complete a comparative examination of the contralateral extremity

when clinically indicated. Finally, ultrasound can provide precise, real-time

guidance for interventional procedures. Compared with radiographs and CT

scans, ultrasound can demonstrate soft tissues with great detail, enabling

safe and accurate needle guidance for interventional procedures. Similar to

ultrasound, MRI provides excellent soft tissue visualization, but the

requirement for nonferromagnetic instrumentation coupled equipment size

and expense currently limit MRI use for real-time interventional procedures.

(Smith etal . , 2009)

Dynamic assessment during contraction and relaxation of the structure

of interest is essential. This helps in establishing the exact relationship of the

mass with the muscle and or the tendon. Soft tissue masses in the anterior

abdominal wall should also be evaluated during deep inspiration and

Introduction

3

expiration to define the relationship of the mass with the peritoneum .

(Kinare etal . , 2007)

Physicians should recognize several clinically relevant limitations of

musculoskeletal ultrasound. Perhaps the most important limitations pertain

to field of view and penetration. Ultrasound provides a very high quality

picture of a relatively small area. Clinicians should use ultrasound to

confirm or characterize pathological changes within a defined body region.

ultrasound‟s limited resolution at greater depths and inability to penetrate

bone limit its ability to adequately image deep body regions, morbidly obese

patients, areas deep to bones, and central intra-articular regions. Finally, as

an interactive and technologically intensive examination, musculoskeletal

ultrasound is also limited by both the ultrasound machine and the skill of the

examiner using it. (Smith etal . , 2009)

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. The presence of Doppler signal can also help

differentiate solid from cystic lesions. (James . , 2006).

US have a high sensitivity when detecting tumors, but it has not

proven to be useful in differentiating benign from malignant conditions.

Power Doppler US (PDUS) or color Doppler US (CDUS) and spectral

analysis can depict the vascular irregularities in malignant tumor, but the

reported criteria for malignancy vary widely. (Chiou et al . , 2009).

HRUS does have a high sensitivity in detecting tumors. Recent advances in

ultrasound technology have enabled the echotexture of soft tissue tumors to

be presented in greater detail. (Chiou et al . , 2007).

Using split-screen technology (which basically allows combining two

images from two adjacent areas) the field of view can be doubled to 12 cm.

Extended field of view enable panoramic imaging with real time probes.

Aim of the work

4

AIM OF WORK

Aim of the work

5

Aim of the work:

To evaluate the usefulness and high light the indications, advantages

and disadvantages of high-resolution grayscale and color Doppler ultrasound

evaluation in musculo-skeletal soft tissue masses and to differentiate benign

from malignant masses.

Technique &Sonographic anatomy of the musculoskeletal system

6

TECHNIQUE &

SONOGRAPHIC

ANATOMY OF THE

MUSKULOSKELETAL

SYSTEM

Ultrasound technique

7

MUSCULOSKELETAL ULTRASOUND

THE PREREQUISITES

Musculoskeletal ultrasound is perhaps the most operator dependent imaging

modality currently available. The primary reason for this is the need to physically

acquire an acceptable image, using appropriately adjusted equipment, with specific

attention to transducer positioning, all within the context of an in-depth

understanding of neurological and musculoskeletal anatomy (Bates , 2004).

To successfully integrate diagnostic or interventional musculoskeletal

ultrasound into clinical practice, the practitioner must therefore acquire the

necessary equipment, education, and scanning skills (Bates , 2004).

Ultrasound Equipment

Types of probes used in musculoskeletal examinations (John et al . ,2007):

Linear Array Probes

Linear array probes have a flat face along which a sequence of crystals is

arranged. The sector size of the linear probe is identical to the footprint of the

probe itself and the resulting image is rectangular or square (Fig. 1). Linear probes

are generally used to view superficial structures and are therefore constructed to

produce higher frequencies. Linear probes are used for various musculoskeletal

applications (John et al . ,2007).

Convex Array Probes

The crystals in convex arrays are arranged along a curved face. The resulting

image has a sector size larger than the footprint of the probe. The range of

frequencies and overall construction of curved array probes are important

Ultrasound technique

8

determinants regarding where they are most beneficial. Larger footprint probes

with less curvature typically provide greater lateral resolution at a given frequency

in the far fields. However, smaller footprint probes with a tighter curvature allow

for easier access through the intercostal spaces. (Fig.1 , 2 &3 ) (John et al. ,2007).

Figure 3: Commonly used ultrasound transducers in musculoskeletal ultrasound. Left, High-

frequency (15-7 MHz), small footprint, linear array transducer, also called a “hockey stick”

transducer. Center, High-frequency (17-5 MHz) linear array transducer. Right, Low- to

medium-frequency (5-2 MHz) curvilinear array transducer. Both linear transducers are used

for superficial imaging, whereas the curvilinear transducer’s lower frequency facilitates

examination of deeper regions such as the hip (Philips iU22 Ultrasound Machine; Philips

Medical Systems, Bothell, WA) (Bates , 2004).

Figure 1: Curved probe , provides

curved image and for powerful

penetration( John et al. ,2007)

Figure 2: Linear probe, linear image.

The linear probe with high frequency

provides excellent superficial

resolution (John et al., 2007).

Ultrasound technique

9

Protocol for ultrasound of superficial lumps

Equipment selection and technique : (Martino et al. , 2006)

Use of a high resolution probe (7-15 MHZ) is essential when assessing

superficial structures.

Careful scanning technique to avoid anisotropy (and possible misdiagnosis).

Use panoramic to get both edges in the same image

May need to use a curved linear array probe if it travels deep or it is a high

attenuating lesion with calcification etc

Beam steering or compounding can help to overcome anisotropy in linear

structures such as tendons.

Good color / power / Doppler capabilities when assessing vessels or

vascularity of a structure.

Be prepared to change frequency output of probe (or probes) to adequately

assess both superficial and deeper structures. (Martino et al. , 2006)

I. Role of grey scale ultrasound : (Chiou etal . ,2009). Location :

Label surrounding anatomy; use a body marker on the film.

Compare to the other side

Measure

in 3 planes:

1. Anterior-posterior .

2. Longitudinal

3. Transverse.

Tumor size was defined as large (> 5 cm), medium (1–5 cm) or small

(< 1 cm).

Volume

Echogenicity:

Hypo, hyper, isoechoic ,anechoic, calcified compared to the surrounding

tissue and its composition was solid, cystic, necrotic content or septate.

Texture:

Homogenous, heterogeneous, simple or complex.

Ultrasound technique

10

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)

Shape :

Was defined as round, ovoid, lobulated or scalloped

Check the lump for spread into the muscle:

Has it broken the fascia, the skin or invasion anywhere else

Is it compressing any vessels or ducts

Shadowing ,posterior enhancement or no change . (Chiou,etal,2009).

II. Role of spectral ,color & power Doppler ultrasound :

Use the Spectral Doppler Trace

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 (Fig. 4) (James, 2006).

Figure 4: Arteriovenous malformation of the thigh. (A) Color Doppler showing a large

serpiginous feeding vessel. (B) Spectral Doppler trace confirms phasic, arterial flow.

(James , 2006) .