Crack The Core 2 > 7. Soft Tissue > Flashcards

7. Soft Tissue Flashcards

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1
Q

What percentage of soft tissue masses/tumors can be accurately diagnosed?

A

20-30%

Most soft tissue masses are T2 bright and enhance, complicating diagnosis.

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2
Q

Name one type of soft tissue tumor that is also known as Pleomorphic Undifferentiated Sarcoma.

A

Malignant Fibrous Histiocytoma (MFH)

The name change to Pleomorphic Undifferentiated Sarcoma (PUS) is recent, but MFH is still commonly used.

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3
Q

List the types of soft tissue masses mentioned.

A
  • Malignant Fibrous Histiocytoma (MFH)
  • Synovial Sarcoma
  • Lipoma, Atypical Lipoma, Liposarcoma
  • Hemangioma

These are key soft tissue masses to know for diagnosis.

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4
Q

True or false: Malignant Fibrous Histiocytoma (MFH) is commonly seen in young people.

A

FALSE

MFH is very common in older individuals.

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5
Q

What is a common location for Malignant Fibrous Histiocytoma (MFH)?

A

Proximal arms and legs

This location is typical for MFH in older patients.

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6
Q

What is a notable feature of MFH regarding its appearance on T2-weighted MRI?

A

Variable (dark to intermediate)

Most soft tissue tumors are T2 bright, making MFH’s appearance notable.

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7
Q

What can be associated with MFH due to its blood supply?

A

Spontaneous hemorrhage

This can occur, especially in cases where the patient has a history of minor trauma.

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8
Q

What is a potential risk factor for developing MFH?

A

Radiation

Radiation exposure is known to increase the risk of sarcomatous transformation.

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9
Q

Fill in the blank: Bone infarcts can turn into _______.

A

MFH

This is referred to as sarcomatous transformation of infarcts.

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10
Q

What is the most common age range for patients with Synovial Sarcoma?

A

20-40

Synovial Sarcoma is seen most commonly in the peripheral lower extremities of patients within this age range.

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11
Q

True or false: Synovial Sarcomas involve the joint.

A

FALSE

For the purpose of multiple choice tests, Synovial Sarcomas ‘never involve the joint’, although they may have secondary invasion into the joint in 10% of cases.

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12
Q

What is the location of a Baker’s Cyst?

A

Between the medial head of the gastrocnemius and the semimembranosus

If a cyst is not located here, consider Synovial Sarcoma and the next step should be MRI.

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13
Q

List the three ways to show Synovial Sarcoma on imaging.

A
  • Triple sign (high, medium, low signal in the same mass)
  • Bowl of grapes (fluid-fluid levels in a mass)
  • Plain x-ray with soft tissue component and calcifications

These imaging characteristics help differentiate Synovial Sarcoma from other conditions.

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14
Q

What are the key characteristics of Synovial Sarcoma?

A
  • Can attack bones
  • Often presents as a painful mass
  • Soft tissue calcifications + bone erosions are highly suggestive
  • Slow growing and small in size
  • 90% have a translocation of X-18
  • Most common malignancy in teens/young adults of the foot, ankle, and lower extremity

These characteristics help in the diagnosis and differentiation from benign conditions.

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15
Q

When I say ‘Ball-like tumor’ in the extremity of a young adult, you say _______.

A

Synovial Sarcoma

This phrase is a mnemonic to remember the association with Synovial Sarcoma.

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16
Q

When I say ‘Soft Tissue Tumor in the Foot of a young adult, you say _______.

A

Synovial Sarcoma

This phrase is a mnemonic to remember the association with Synovial Sarcoma.

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17
Q

What is the typical T2 signal appearance of Synovial Sarcoma in young patients?

A

Triple Sign

This refers to the presence of high, medium, and low signal all in the same mass, likely in the knee.

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18
Q

What is the typical T2 signal appearance of MFH (PUS) in older patients?

A

Variable (Sometimes Dark)

This indicates that the imaging characteristics can vary significantly.

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19
Q

What is the spectrum of lipomatous tumors from benign to malignant?

A
  • Lipoma
  • Atypical Lipoma
  • Liposarcoma

Lipoma is totally benign, while Liposarcoma is malignant.

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20
Q

True or false: Atypical Lipoma behaves and looks just like a low-grade Liposarcoma.

A

TRUE

The distinction between Atypical Lipoma and Liposarcoma can be challenging.

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21
Q

What are the imaging characteristics of Liposarcoma?

A
  • T2 bright
  • Enhances
  • Signal intensity parallels fat on all sequences
  • May have parts that are slightly darker or brighter than fat on T1

These characteristics help differentiate Liposarcoma from other tumors.

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22
Q

What is a key next step in evaluating a suspected Liposarcoma?

A

Will Fat Sat Out

This helps determine if the tumor is indeed a Liposarcoma.

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23
Q

What are the characteristics of Liposarcomas compared to Lipomas?

A
  • Liposarcomas tend to be DEEP (retroperitoneum)
  • Liposarcomas tend to be BIG
  • Lipomas tend to be Superficial

These distinctions can aid in diagnosis.

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24
Q

What is the most common liposarcoma in patients under 20?

A

Myxoid Liposarcoma

Myxoid Liposarcoma is T2 bright and T1 dark, which can be confusing.

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25
What imaging modality is considered **best** for staging and follow-up of tumors?
MR (Magnetic Resonance) ## Footnote MR is better for staging and following therapy.
26
What are the **characteristics** of Myxoid Liposarcoma?
* T2 Bright * T1 Dark * Requires gadolinium for better imaging ## Footnote It is important not to misinterpret it as a cyst.
27
What are the **key characteristics** of a **hemangioma**?
* T2 bright * Flow voids * Infiltrates into surrounding tissues * Enhances intensely * Can contain fat ## Footnote Hemangiomas are common vascular tumors with unique imaging features.
28
Mazabraud Syndrome has **three main findings**. Name them.
* Polyostotic Fibrous Dysplasia * Multiple Soft Tissue Myxomas * Difficulty finding a date to the prom ## Footnote This syndrome is considered a 'zebra syndrome' due to its rarity.
29
What is a **next step** question regarding Mazabraud Syndrome?
Ask for a plain film ## Footnote A plain film can reveal soft tissue phleboliths, aiding in diagnosis.
30
What do **myxomas** typically look like on MRI?
* T2 bright * Lower signal than muscle on T1 ## Footnote Myxomas are often associated with Mazabraud Syndrome.
31
What is **CT** good for in lesion characterization?
* Occult Bone Destruction * Matrix and Mineralization ## Footnote CT provides better visualization of certain bone lesions.
32
What is **MRI** good for in lesion characterization?
* Staging * Local extent and tumor spread * Follow up to assess response to therapy ## Footnote MRI is preferred for evaluating soft tissue and tumor response.
33
What is the treatment protocol for **Osteosarcoma**?
* Chemo first * Followed by wide excision ## Footnote This approach targets micro metastases before surgical intervention.
34
What is the treatment protocol for **Ewing's Sarcoma**?
* Both Chemo and Radiation * Followed by wide excision ## Footnote This combination is crucial for managing this aggressive tumor.
35
What is the typical treatment for **Chondrosarcoma**?
* Usually just wide excision ## Footnote Chondrosarcomas are often low grade, with local recurrence being the main concern.
36
What is the treatment requirement for a **Giant Cell Tumor**?
* Usually requires arthroplasty ## Footnote This is due to the tumor's extension to the articular surface.
37
What is **Pigmented Villonodular Synovitis (PVNS)**?
An uncommon benign neoplastic process involving the synovium of the joint or tendon sheath ## Footnote PVNS is characterized by synovial proliferation and hemosiderin deposition, commonly affecting the knee (65-80%).
38
What are the typical **plain film features** of PVNS?
* Joint effusion * Marginal erosions * Osseous erosions with preservation of the joint * Normal mineralization ## Footnote It is difficult to distinguish PVNS from synovial chondromatosis on plain film.
39
What is the **recurrence rate** after treatment for PVNS?
20-50% ## Footnote Treatment typically involves complete synovectomy.
40
True or false: PVNS is common in children.
FALSE ## Footnote When present in children, PVNS is typically polyarticular.
41
Where is the **Giant Cell Tumor of the Tendon Sheath** typically found?
In the hand (palmar or digital tendons) ## Footnote It can cause erosions on the underlying bone.
42
What is the primary type of **Synovial Chondromatosis**?
A metaplastic/neoplastic process resulting in multiple cartilaginous nodules in the synovium ## Footnote It usually affects one joint, typically the knee (70%), and can progress to loose bodies.
43
What is the typical age range for patients with **Primary Synovial Chondromatosis**?
40's to 50's ## Footnote Joint bodies may demonstrate chondroid calcification.
44
What is the difference between **Primary** and **Secondary Synovial Chondromatosis**?
* Primary: true neoplastic process, multiple nodules * Secondary: results from degenerative changes, fewer and larger fragments ## Footnote Secondary type is lower yield and typically seen in older patients.
45
What is **Diabetic Myonecrosis**?
Infarction of muscle seen in poorly controlled type I diabetics ## Footnote It typically involves the thigh (80%) or calf (20%) and shows marked edema with enhancement on MRI.
46
What should you NOT do when diagnosing **Diabetic Myonecrosis**?
Do NOT biopsy ## Footnote Biopsy delays recovery and has a high complication rate.
47
What is **Lipoma Arborescens**?
A zebra that affects the synovial lining of the joints and bursa ## Footnote Characterized by 'frond-like' deposition of fatty tissue, typically seen in late adulthood.
48
What is the **buzzword** associated with Lipoma Arborescens?
'Frond-like' deposition of fatty tissue ## Footnote This term describes the appearance of the fatty tissue in the condition.
49
In which age group is **Lipoma Arborescens** most commonly seen?
50's-70's ## Footnote It typically affects individuals in late adulthood.
50
What is the most common location for **Lipoma Arborescens**?
Suprapatellar bursa of the knee ## Footnote Although it can develop in a normal knee, it is often associated with conditions like OA or Chronic RA.
51
On MRI, how does **Lipoma Arborescens** behave?
* T1 bright * T2 bright * Responds to fat saturation ## Footnote It behaves like fat on MRI imaging.
52
What imaging trick can be used to identify **Lipoma Arborescens**?
Show on gradient to pick up the chemical shift artifact at the fat-fluid interface ## Footnote This technique helps in visualizing the condition more effectively.
53
How can **Lipoma Arborescens** be shown on ultrasound?
Frond-like hyperechoic mass and joint effusion ## Footnote Ultrasound can provide a visual representation of the condition.
54
What is **Tumoral Calcinosis** characterized by?
Big lobular/cystic calcium near a joint ## Footnote It is associated with fluid-calcium levels visible on CT.
55
What joints are most commonly affected by **Tumoral Calcinosis**?
* Hip * Elbow * Shoulder ## Footnote The knee is considered rare for this condition.
56
What is the most common site for **Tumoral Calcinosis**?
Greater Trochanteric Bursa ## Footnote This site is frequently involved in the condition.
57
What does **Primary Synovial Chondromatosis** consist of?
Multiple, small, uniformly sized, ossified nodules near a joint ## Footnote It is considered 'secondary' if there are degenerative changes.
58
What is the most common joint affected by **Primary Synovial Chondromatosis**?
Knee (~70%) ## Footnote This condition predominantly affects the knee joint.
59
What are the characteristics of **Metastatic Calcification**?
* Fine and diffuse soft tissue calcifications * Seen in renal and lung calcifications ## Footnote It is often associated with renal failure or hyperparathyroidism.
60
How does **Metastatic Calcification** differ from **Tumoral Calcinosis**?
* Elevated calcium levels in Metastatic Calcification * Tumoral Calcinosis can have fluid-calcium levels ## Footnote The lab results help differentiate between the two conditions.
61
What are **Danion Lesions**?
Lesions that look aggressive but are NOT of possibly misleading pathology ## Footnote These lesions can be mistaken for more serious conditions.
62
What are **benign lesions** that look aggressive but should NOT be biopsied?
* Myositis Ossificans * Avulsion Injury * Cortical Desmoid * Synovial Herniation Pit ## Footnote These lesions can present misleading pathology and may appear aggressive on imaging.
63
Describe the appearance of **Myositis Ossificans** on MRI.
Circumferential calcifications with a lucent center ## Footnote It can look scary on MRI and is often imaged early due to associated edema and enhancement.
64
Where is the typical location for an **Avulsion Injury**?
Near the pelvis ## Footnote It can have an aggressive periosteal reaction.
65
What is the characteristic location of a **Cortical Desmoid**?
Posterior medial epicondyle of the distal femur ## Footnote It can be hot on bone scans and is bilateral 30% of the time.
66
True or false: A **Cortical Desmoid** is actually a desmoid tumor.
FALSE ## Footnote It is actually a lesion from the medial gastrocnemius and adductor magnus.
67
What is the characteristic location of a **Synovial Herniation Pit**?
Anterosuperior femoral neck ## Footnote It is associated with femoral acetabular impingement syndrome.
68
What should be discussed with the orthopedic surgeon before a **bone biopsy**?
The route of biopsy ## Footnote This is to avoid contaminating compartments not involved by the tumor.
69
What special consideration should be taken for a **pelvis biopsy**?
Avoid crossing gluteal muscles ## Footnote These muscles may be needed for reconstruction.
70
What should be avoided during a **knee biopsy**?
* Crossing the joint space * Crossing suprapatellar bursa * Crossing the quadriceps tendon ## Footnote These areas may lead to complications or contamination.
71
What area should be avoided during a **shoulder biopsy**?
Posterior 2/3rd ## Footnote The axillary nerve courses posterior to anterior, so a posterior resection will denervate the anterior 1/3.
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