Intramuscular Lesions Research Articles

Immunohistochemical and FISH analysis of MDM2 and CDK4 in a dedifferentiated extraskeletal osteosarcoma arising in the vastus lateralis muscle: Differential diagnosis and diagnostic algorithm

Extraskeletal osteosarcoma is a rare neoplasia within the broad differential diagnostic spectrum of calcifying intramuscular lesions. We present a case of a slowly increasing mass within the left vastus lateralis muscle. At first presentation the patient showed a partially calcified well defined mass with a diameter of 5cm and with no direct contact to the femur. A biopsy from the periphery revealed an ossifying lesion compatible with myositis ossificans. The patient returned 18 months later with the lesion having increased to a diameter of 25cm. The resection specimen revealed a well delimitated tumor with a central core of partially necrotic neoplastic bone. Besides, histology showed high mitotic areas with pleomorphic spindle cells and regions with cartilaginous differentiation. Immunohistochemistry demonstrated: vimentin+, CD34−, desmin−, actin−, EMA− and pancytokeratin− with focal S100 protein positivity and a Ki-67 index of 20%. Comparative genomic hybridization (CGH) revealed a gain of chromosomal material on 12q; FISH analyses for the CDK4 and MDM2 region showed high level amplifications. Consequently, a high-grade dedifferentiated extraskeletal osteosarcoma was diagnosed. In conclusion, analysis of the MDM2 and CDK4 status is a powerful and discriminating diagnostic tool to distinguish dedifferentiated extraskeletal osteosarcoma from other benign/malignant ossifying lesions in the skeletal muscle.

Fibro-Adipose Vascular Anomaly

The diagnosis and management of vascular anomalies of the extremities can be challenging as these disorders are uncommon and may clinically overlap. The aim of this paper is to describe the clinical, radiologic, and histopathologic features of fibro-adipose vascular anomaly (FAVA), a previously unrecognized disorder of the limb. The clinical, imaging, operative, and histopathologic data from patients with a unique intramuscular lesion of the extremities comprising dense fibrofatty tissue and slow-flow vascular malformations were retrospectively reviewed. Sixteen patients diagnosed with FAVA of the extremity (3 male and 13 female individuals) met the clinical, radiologic, and histopathologic inclusion criteria. The age at presentation ranged from the time of birth to 28 years. The locations of the lesions were: calf (n=10), forearm/wrist (n=3), and thigh (n=3). Fourteen patients presented with severe pain. Seven of the patients with calf lesions had limited ankle dorsiflexion. On imaging, the complex intramuscular lesions replaced muscle fibers with fibrofatty overgrowth and phlebectasia (dilation of the veins). The extrafascial component comprised fatty overgrowth, phlebectasia, and an occasional lymphatic malformation. The histopathologic features comprised dense fibrous tissue, fat, and lymphoplasmacytic aggregates within atrophied skeletal muscle. Adipose tissue also infiltrated skeletal muscle at the periphery of the lesion. There were large, irregular, and sometimes excessively muscularized venous channels and smaller, clustered channels. Other findings include organizing thrombi, a lymphatic component, and dense fibrous tissue-encircled nerves. The constellation of clinical, radiologic, and histopathologic features constitutes a distinct entity comprising fibrofatty infiltration of muscle, unusual phlebectasia with pain, and contracture of the affected extremity. The clinical and radiologic findings permit the diagnosis of FAVA with major therapeutic implications. Level III.

Malignant and Benign Lesions of the Skeletal Musculature

There are several tumors and tumorlike conditions with variable biological behavior that may involve the skeletal musculature. The aim of this work was to review different intramuscular lesions and to provide a classification of muscle lesions based on their radiological patterns as well as to provide as a pictorial essay the imaging characteristics of typical muscle lesions. Radiologically, intramuscular lesions can manifest as solid masses, liquid or semiliquid masses, fat-containing lesions, diffuse muscle enlargement, and muscle calcifications. Additionally, lesions with mixed patterns can also occur. It is noteworthy that different malignant or benign muscle lesions can manifest with identical radiological patterns.

Extensive ossification of an intramuscular venous malformation in the submental region

We describe a 62-year-old male patient with an extensively ossified venous malformation within the mylohyoid muscle. Phleboliths and calcifications are characteristic of venous malformations, while massive ossification is rare. To our knowledge, no extensive ossified venous malformation within the mylohyoid muscle has been reported. Intramuscular vascular lesions occur with an incidence of 0.8 in 10, occurring in the head and neck region in 15% of cases. Most are venous malformations. The diagnosis is rarely made before surgery and requires a definitive histological analysis, as there are no pathognomonic clinical or radiographic findings, especially with extensive ossification. Spontaneous regression does not occur, and treatment must be based on aesthetic and functional disturbances. We reviewed the classification of vascular anomalies, focusing on differentiating between venous malformations and haemangiomas, which are frequently confused in the literature.

English

BACKGROUND: Cysticercosis commonly presents as neural or intramuscular lesion. Rarely, it may present in soft tissues in the adult age group. CASE DETAILS: A 42-year- old male presented with pain and swelling over the right lateral abdominal wall. The pain was progressive towards sub-costal region. It was clinically diagnosed as Fibromatosis / Desmoid tumor. Abdominal ultra-sound revealed possibility of Desmoid / Dermoid / Infective cyst. Surgical excision was performed. The final diagnosis of Subcutaneous Cysticercosis was made based on the histopathological findings. CONCLUSION: Even though cysticercosis is common in brain and skeletal muscle, it is rare at subcutaneous location. Therefore the possibility of cysticercosis should be considered in the differential diagnosis of subcutaneous swelling in the

Intramuscular Dissection of a Large Ganglion Cyst Into the Gastrocnemius Muscle

Ganglion cysts are lesions resulting from the myxoid degeneration of the connective tissue associated with joint capsules and tendon sheaths. Most common around the wrist joint, ganglion cysts may be found elsewhere in the body, including in and around the knee joint. Uncommonly, ganglion cysts can present intramuscularly. Previous reports document the existence of intramuscular ganglia, often without histologic confirmation. This article describes a case of an intramuscular ganglion cyst in the medial gastrocnemius muscle of a 53-year-old woman. The patient initially presented for discomfort associated with the lesion. Examination was consistent with intramuscular cystic lesion of unknown etiology. Ultrasound and magnetic resonance imaging revealed the origin of the mass at the semimembranosus-gastrocnemius bursa. Because of its location, the mass was initially suspected to be a dissecting Baker's cyst, an uncommon but previously reported diagnosis. The patient underwent surgical excision, and examination of the intact specimen revealed a thin, fibrous, walled cyst with no lining epithelium, which was consistent with a ganglion cyst. To the authors' knowledge, this is the first report in the orthopedic literature of a ganglion cyst dissecting into the gastrocnemius muscle. Because ganglion cysts commonly require excision for definitive treatment and do not respond well to treatment measures implemented for Baker's cysts, including resection of underlying meniscal tears, the authors believe it is important for orthopedic surgeons to be able to distinguish between Baker's and other cysts associated with the knee joint, including ganglion cysts, which may require more definitive treatment.

PTEN Hamartoma of Soft Tissue

PTEN hamartoma tumor syndrome (PHTS) presents in a spectrum that encompasses the eponymous disorders Cowden and Bannayan-Riley-Ruvalcaba. Herein, we delineate the distinctive histopathology of a predominantly intramuscular lesion in PHTS, often called "arteriovenous malformation," because of certain imaging and histopathologic features. Cases were identified by review of lesions resected from patients with PHTS registered at our Vascular Anomalies Center and of unusual intramuscular vascular anomalies in our pathology database from 1985 to 2008. Thirty-four patients with this lesion were identified: 20 had a clinical diagnosis of, or were suspected to have, PHTS (genetically confirmed in 16). In 4 patients without clinical manifestations of PHTS, 2 had PTEN mutations, 1 did not, and in 1 the mutation was intronic. In the remaining 10, there was insufficient clinical information to fully assess whether they had manifestations of PHTS. Lesions manifested by 15 years of age, normally with pain and swelling, and were most often located in the lower extremity. The major mass was usually intramuscular, but often there were fascial and subcutaneous components and not infrequently a cutaneous vascular stain. Magnetic resonance imaging generally showed an infiltrative soft tissue lesion involving the muscle, fascia, and subcutis with frequently enlarged, serpiginous vessels, small arteriovenous fistulae with disproportionately dilated draining veins, and a prominent adipocytic component. Some lesions involved contiguous muscles, and 20% were multifocal. Resected specimens ranged in size from 1.2 to 25 cm; in 1 patient, amputation was necessary. Histopathologically, these unencapsulated masses, often with a nodular appearance at scanning magnification, consisted of: (1) a variable admixture of mature adipocytic and dense and/or myxoid fibrous tissues (50% to 90% of surface area); (2) a vascular component (10% to 50% of surface area) with: (a) clusters of venous channels, some with excessively and irregularly muscularized complex walls and lumens, and others with thin walls resembling pulmonary alveoli, (b) tortuous, thick-walled arteries with concentric muscular hyperplasia and relatively small lumens, (c) numerous small vessels (arteries, veins, and indeterminate channels), and (d) occasional arteriovenous communications; (3) lymphoid follicles (50%); (4) foci of bone (20%); and (5) hypertrophic nerves with "onion bulb" proliferation of periaxonal spindled cells (9%). We designate this disorganized overgrowth of essentially mesenchymal elements as PTEN hamartoma of soft tissue. It differs from other vascular and connective tissue lesions that occur in patients with PHTS. PTEN hamartoma of soft tissue is histopathologically distinctive, and its identification should prompt a thorough investigation for PHTS.

A Case of Cysticercosis with Multiple Intracerebral and Intramuscular Nodular Lesions

A 47-year-old Chinese woman with no significant medical history admitted for sudden-onset seizures and transient right homonymous hemianopsia had moved from China to Japan 4 years previously. Contrast brain computed tomography (CT) showed multiple calcified nodular lesions with surrounding edema, one in the left parietal lobe being likely responsible for her visual symptoms. After admission, two painful intramuscular nodular lesions were found in her left lower limb. Histopathologically biopsy specimens from these lesions were not diagnostic. Serum antibody testing (ELISA) for Taenia solium, however, was positive, yielding a diagnosis of (neuro) cysticercosis. The woman responded well to albendazole and prednisolone treatment. In the two years since discharge, she has not developed any new symptoms or seizure recurrence. With increasing global travel, clinicians must thus consider the possibility of neurocysticercosis in cases of nodular brain lesions in subjects from areas where Taenia solium remains endemic.

Diagnostic value of delineating deep fascia in distinguishing between benign and malignant soft-tissue tumors in lower limbs using 3.0 T magnetic resonance imaging

To determine the association between morphological changes to the deep fascia and the malignancy of soft-tissue tumors in the lower limbs using 3.0 T magnetic resonance imaging (MRI). MR images of 47 consecutive patients with 48 pathologically proven soft-tissue tumors in the lower limbs were retrospectively reviewed by two radiologists. Lesions were divided into four groups according to their predominant location relative to the deep fascia: Group A: subcutaneous lesions superficial to the deep fascia (n = 9); Group B: lesions located beneath the deep fascia (n = 8); Group C: lesions centered in the interspaces of the deep fascia investment (n = 11); and Group D: intramuscular lesions (n = 20). The deep fascial structures were complete in all of the 19 benign lesions. In malignant lesions, destruction signs of the deep fascia were observed in 27 of the 29, which were characterized by disappearance/disruption of the fascial line and aggressive growth penetrating through the fascial line into the adjacent compartment, or disappearance/disruption of the intermuscular septa and embedding the mutilated fascial septa within the lesion, or destruction of the fascia-muscle planes and abolishment of the deep fascial interspaces. Diagnosis of malignancy based on the signs of destruction of the deep fascial structure delineated with 3.0 T MRI, the sensitivity, specificity, and accuracy were 93.10%, 100%, and 95.83%, respectively. Tumor involvement and destruction of the deep fascial structures visualized by 3.0 T MRI may be of utility in differentiating malignant from benign soft-tissue tumors.

Detection of Papillary Thyroid Cancer Brain Metastasis With FDG-PET/CT

Abstract:A 70-year-old woman with a history of papillary thyroid carcinoma metastatic to lung and arm muscle previously was treated with total thyroidectomy, pneumonectomy, excision of an intramuscular lesion, and I-131 therapy. Because of an elevated serum thyroglobulin level, she underwent Thyroge

PET/CT-Guided Percutaneous Biopsy of Isolated Intramuscular Metastases from Postcricoid Cancer

(18)F-FDG PET/CT has made it possible to identify many unsuspected lesions such as isolated intramuscular metastases because of its ability to detect abnormal metabolic activity in an early stage even without clinical symptoms or morphologic changes. We need to modify our routine techniques for performing biopsies of such lesions because they may not be visualized on morphologic imaging. We describe a technique in which fused PET/CT is used to guide the percutaneous biopsy needle for sampling isolated intramuscular metastatic lesions in a patient whose intramuscular metastases were identified only on PET/CT, not on CT or ultrasound, and were clinically occult.

Synthesis and evaluation of 99mTc-moxifloxacin, a potential infection specific imaging agent

To synthesize and evaluate a 99mTc labeled fluroquinolone, moxifloxacin as a potential bacteria specific infection imaging agent. A radiolabeling formulation including moxifloxacin, [Moxicip TM injection, Cipla] (4 mg), sodium pertechnetate and stannous chloride (5 μg) gave the best radiolabeling efficiency and moderately stable labeled 99mTc moxifloxacin. Quality control analysis was performed by ITLC. Rats and rabbit with infectious intramuscular lesions induced in either thigh with E. Colli were used for studying biodistribution and scintigraphic imaging of the labeled product. Imaging of an infected thigh of a rabbit was performed with a γ-camera at various intervals. A good radiolabeling efficiency (90–95%) was obtained within 5 min. No purification of the labeled product was done. Labeled product retained its radiochemical purity upto 85% even at 3 h. Scintigraphy showed uptake in infectious lesions at 30 min after injection, which remains constant upto 3 h study. Abscess-to-muscle ratios were 1.60, 1.62, 1.74 and 1.75 at 30 min, 1, 2 and 3 h, respectively. Thus, 99mTc moxifloxacin, a new potential radiopharmaceutical has been developed for infection imaging agent.

The diagnostic value of diffusion-weighted magnetic resonance imaging in soft tissue abscesses

Purpose To study the diagnostic value of diffusion-weighted imaging (DWI) in soft tissue abscesses. Materials and methods Fifty patients were included in this study who were thought to have soft tissue abscess or cystic lesion as a result of clinical and radiological examinations. Localisations of the lesions were: 1 periorbital, 3 breast, 14 intraabdominal, and 32 intramuscular lesions. After other radiological examinations, DWI was performed. The signal intensity values of the lesions were evaluated qualitatively according to the hyperintensity on b-1000 DWI, using 1.5 T MR system. All of the lesions were aspirated after DWI, and detection of pus in the aspiration material was accepted as gold standard for the diagnosis of abscess. Results In 38 of the 50 patients, hyperintensity was obtained on diffusion-weighted images. False-positive results were maintained in 2 of these patients, and true-positive results were maintained in 36 of them. In 11 of the 50 patients, hypointensity was visualised on diffusion-weighted images. False-negative results were maintained in 3 of these patients, and true-negative results were maintained in 8 of them. An abscess which was seen on post-contrast conventional MRI could not be seen on DWI, and this was regarded as false-negative. Conclusion The sensitivity and specificity of diffusion-weighted images for detecting soft tissue abscesses were found to be 92% and 80%, respectively. DWI has a high diagnostic value in soft tissue abscesses, and is an important imaging modality that may be used for the differentiation of cysts and abscesses.

Skeletal muscle metastases: primary tumours, prevalence, and radiological features

Although skeletal muscles comprise nearly 50% of the total human body mass and are well vascularised, metastases in the musculature are rare. The reported prevalence of skeletal muscle metastases from post-mortem studies of patients with cancer is inconstant and ranges from 0.03 to 17.5%. Of 5,170 patients with metastasised cancer examined and treated at our institution during the period from January 2000 to December 2007, 61 patients with muscle metastases (80 lesions) were identified on computed tomography (CT). Genital tumours (24.6%) were the most frequent malignancies metastasising into the skeletal musculature, followed by gastrointestinal tumours (21.3%), urological tumours (16.4%), and malignant melanoma (13.1%). Other primary malignancies were rarer, including bronchial carcinoma (8.2%), thyroid gland carcinoma (4.9%), and breast carcinoma (3.3%). In 8.2%, carcinoma of unknown primary was diagnosed. Skeletal muscle metastases (SMM) were located in the iliopsoas muscle (27.5%), paravertebral muscles (25%), gluteal muscles (16.3%), lower extremity muscles (12.5%), abdominal wall muscles (10%), thoracic wall muscles (5%), and upper extremity muscles (3.8%). Most (76.3%) of the 80 SMM were diagnosed incidentally during routine staging CT examinations, while 23.7% were symptomatic. Radiologically, SMM presented with five different types of lesions: focal intramuscular masses (type I, 52.5% of SMM), abscess-like intramuscular lesions (type II, 32.5%), diffuse metastatic muscle infiltration (type III, 8.8%), multifocal intramuscular calcification (type IV, 3.7%) and intramuscular bleeding (type V, 2.5%).

Toxicité de l’association radiothérapie et antiangiogéniques : à propos d’un cas

The combined administration of antiangiogenic agents (AA) and radiation is being evaluated. No AA has yet received Marketing Authorization in this indication. However, they are widely used in medical oncology and criteria for stopping their administration in case of irradiation have not been defined. We report the case of a 63-year-old man experiencing grade 2 skin toxicity while on radiation treatment and sorafenib (400 mg twice daily) for a metastatic lesion developing between the vastus medialis muscle and the cortical of the mid-diaphysis of the right femur. Toxicity occurred at 21 Gy, for a total dose of 36 Gy (12 fractions of 3 Gy). Cutaneous symptoms rapidly disappeared after treatment discontinuation. Radiotherapy alone was resumed after a few days and the total dose could be delivered, with good tolerance. At 2-month follow-up, the intramuscular lesion had regressed. Several other cases of patients with poor tolerance to the association of AA and radiotherapy have been reported. Further studies of the effectiveness and tolerance of the combination treatment are needed before indications for AA can be extended to other diseases.

Ultrasonographic Findings of Subcutaneous and Muscular Sparganosis

Purpose: This study was deigned to evaluate the ultrasonographic findings of subcutaneous and intramuscular sparganosis. Materials and Methods: Nine cases of histologically proven subcutaneous and intramuscular sparganosis lesions in seven patients (mean patient age, 59 years; M:F = 6:1) were reviewed retrospectively. Two patients had recurrent sparganosis. A color Doppler examination was performed in all cases. Results: A prior history of ingestion of raw snake meat was noted for two patients. Patients presented with a palpable mass and induration (n = 7) and dull pain (n = 4). Lesion locations were in the thigh (n = 4), lower leg (n = 2), chest wall (n = 1), an inguinal location (n = 1) and the neck (n = 1). Five lesions were in the subcutaneous fat layer and four lesions had intramuscular locations. Calcification was noted in two cases. All cases showed heterogeneous hypoechoic serpiginous tubular-and-oval lesions. The lesions were conglomerated or discrete in appearance. All nine cases showed the presence of lesions with a multi-layered wall with variable intraluminal echogenicity, at least in one segment of the lesion. Increased vascularity was noted on color Doppler examinations in two patients with pain. Conclusion: Subcutaneous or intramuscular sparganosis should be included in the differential diagnosis when a serpiginous tubular-and-oval lesion is noted that is seen with a multi-layered wall with variable intraluminal echogenicity.

Snapping hip caused by a venous hemangioma of the gluteus maximus muscle: a case report

IntroductionSnapping hip, or coxa saltans, is defined as a clinical condition where a usually painful, audible snap occurs during hip flexion and extension. Its causes can be divided into external, internal or intra-articular origin. Accurate diagnosis is a prerequisite to successful treatment. We report a rare cause of snapping hip which is different from any previously reported cases.Case presentationA 23-year-old man presented to us with right hip pain of more than 10 years duration. Atrophy of the right gluteus maximus with snapping and tenderness were also noted. The imaging study revealed a focal intramuscular lesion in the lateral portion of the right gluteus maximus muscle. Surgery was performed and pathological examination concluded this mass to be a venous hemangioma.ConclusionIntramuscular hemangioma, though rare, should be considered in the differential diagnosis of a snapping hip even though muscle fibrosis is most frequently encountered.

Bilateral sciatica secondary to mass lesions in the gluteal muscles

The MRI revealed well-demarcated solid masses in the left gluteal muscles and the right piriformis muscle showing significant contrast enhancement. Both sciatic nerves were surrounded by the tumor masses, their fibers being thickened with no enhancement with contrast medium (black arrows in Fig.1 in ‘‘Question”). Multicentric intramuscular mass lesions suggest metastasis, leukemia, lymphoma, and sarcoidosis. When patients have a history of cancer, metastasis is supported by clinical and radiological findings. The diagnosis was confirmed via needle biopsy. Although skeletal muscles comprise nearly 50% of the total body mass and have a profuse blood supply, metastatic involvement is quite rare, which is unexplained. It may be related to contractile activity, high tissue pressure, the accumulation of lactic acid, local changes in pH, or oxygenation. The frequency of muscle metastases is reported as 0.8% to 16% in necropsy studies, lung carcinomas being the most usual source. The most commonly involved muscles

Intramuscular and subcutaneous sparganosis: Sonographic findings

A case of subcutaneous and intramuscular sparganosis was confirmed on surgical excision of a worm in a 60-year-old woman suffering from painful masses in the right thigh. Sonography and MRI revealed an ill-defined intramuscular lesion and multiple cystic lesions in the subcutaneous tissue. At the time of the excision, a sparganum larva was found in the adductor longus muscle. If an intramuscular mass with a serpiginous cystic tract is seen on imaging studies in an endemic area, musculoskeletal sparganosis should be included in the differential diagnosis of a soft tissue tumor.

Magnetic resonance imaging of gluteal intramuscular myxoma

Gluteal intramuscular myxomas with MR images have not been reported before. A 45-year-old man presented with a palpable mass in his right buttock for several months. Magnetic resonance imaging showed an intramuscular cystic lesion with homogeneous signal intensity at the right gluteus muscle, and the mass had thin peripheral enhancement after gadolinium administration. The patient was treated by marginal excision of the tumor. Histologic diagnosis was compatible with intramuscular myxoma.