Skip to main content

Small soft tissue masses indeterminate at imaging: histological diagnoses at a tertiary orthopedic oncology clinic

Abstract

Objective

To review histologic diagnoses of soft-tissue masses (STMs) ≤ 2 cm with indeterminate imaging features encountered in musculoskeletal oncology clinic at a tertiary referral center.

Materials and methods

This was an IRB-approved retrospective review of patients with STMs ≤ 2 cm, referred to our tertiary care orthopedic oncology clinic over 4.75 consecutive years. Maximum diameter was based on imaging measurement by a fellowship-trained musculoskeletal radiologist. Simple lipomas, synovial cysts, metastases, and cases without histologic confirmation were excluded. Patient demographics, tumor imaging features (location, depth, size, and tumor:muscle enhancement and T2 signal ratios), and histology were recorded and compared.

Results

Mean maximum diameter for 42 trunk/extremity STMs was 1.5 cm (range, 0.7 to 2 cm). Mean age was 48 years (range, 18–83 years). Nine (21%) of the masses were malignant, while 33 (79%) were non-malignant. Thirty-nine (93%) of masses were superficial; 7/39 (18%) of these superficial tumors were malignant. Malignancy was not associated with underlying vessels, tendon, or fascia (p = 0.19). The non-malignant vs. malignant tumor:muscle enhancement ratio was 2.15 vs. 2.32 (p = 0.58) and enhancement coefficient of variation was 0.14 vs. 0.10 (p = 0.29). Most common malignant histologic subtypes were synovial sarcoma (n = 3), fibroblastic/myofibroblastic sarcoma (n = 2), leiomyosarcoma (n = 2), myxofibrosarcoma (n = 1), and angiomatoid fibrous histiocytoma (n = 1). The majority (67%) of non-malignant lesions were: leiomyoma (n = 6), angiomyoma (n = 5), schwannoma (n = 4), benign fibrous histiocytoma (n = 4), and hemangioma (n = 3).

Conclusions

At a tertiary musculoskeletal oncology referral clinic, primary STMs ≤ 2 cm with indeterminate imaging features should be managed cautiously despite their small size and/or superficial location.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

References

  1. 1.

    Chen CK, Wu HT, Chiou HJ, Wei CJ, Yen CH, Chang CY, et al. Differentiating benign and malignant soft tissue masses by magnetic resonance imaging: role of tissue component analysis. J Chin Med Assoc. 2009;72(4):194–201.

    Article  PubMed  Google Scholar 

  2. 2.

    Amin MB, Edge SB, Greene FL, et al. eds. AJCC Cancer Staging Manual. 8th ed. NewYork: Springer; 2017.

  3. 3.

    Datir A, James SL, Ali K, Lee J, Ahmad M, Saifuddin A. MRI of soft-tissue masses: the relationship between lesion size, depth, and diagnosis. Clin Radiol. 2008;63(4):373–8 discussion 379-80.

    Article  CAS  PubMed  Google Scholar 

  4. 4.

    Gruber L, Gruber H, Luger AK, Glodny B, Henninger B, Loizides A. Diagnostic hierarchy of radiological features in soft tissue tumours and proposition of a simple diagnostic algorithm to estimate malignant potential of an unknown mass. Eur J Radiol. 2017;95:102–10.

    Article  PubMed  Google Scholar 

  5. 5.

    Pretell-Mazzini J, Barton MD Jr, Conway SA, Temple HT. Unplanned excision of soft-tissue sarcomas: current concepts for management and prognosis. J Bone Joint Surg Am. 2015;97(7):597–603.

    Article  PubMed  Google Scholar 

  6. 6.

    Kransdorf MJ, Moser RP Jr, Meis JM, Meyer CA. Fat-containing soft-tissue masses of the extremities. Radiographics. 1991;11(1):81–106.

    Article  CAS  PubMed  Google Scholar 

  7. 7.

    Chung WJ, Chung HW, Shin MJ, Lee SH, Lee MH, Lee JS, et al. MRI to differentiate benign from malignant soft-tissue tumours of the extremities: a simplified systematic imaging approach using depth, size and heterogeneity of signal intensity. Br J Radiol. 2012;85(1018):e831–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Kransdorf MJ, Jelinek JS, Moser RP Jr, Utz JA, Brower AC, Hudson TM, et al. Soft-tissue masses: diagnosis using MR imaging. AJR Am J Roentgenol. 1989;153(3):541–7.

    Article  CAS  PubMed  Google Scholar 

  9. 9.

    Berquist TH, Ehman RL, King BF, Hodgman CG, Ilstrup DM. Value of MR imaging in differentiating benign from malignant soft-tissue masses: study of 95 lesions. AJR Am J Roentgenol. 1990;155(6):1251–5.

    Article  CAS  PubMed  Google Scholar 

  10. 10.

    Saito K, Kobayashi E, Yoshida A, Araki Y, Kubota D, Tanzawa Y, et al. Angiomatoid fibrous histiocytoma: a series of seven cases including genetically confirmed aggressive cases and a literature review. BMC Musculoskelet Disord. 2017;18(1):31.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Gielen JL, De Schepper AM, Vanhoenacker F, Parizel PM, Wang XL, Sciot R, et al. Accuracy of MRI in characterization of soft tissue tumors and tumor-like lesions. A prospective study in 548 patients. Eur Radiol. 2004;14(12):2320–30.

    Article  PubMed  Google Scholar 

  12. 12.

    Kransdorf MJ, Murphey MD. Imaging of soft-tissue musculoskeletal masses: fundamental concepts. Radiographics. 2016;36(6):1931–48.

    Article  PubMed  Google Scholar 

  13. 13.

    Walker EA, Song AJ, Murphey MD. Magnetic resonance imaging of soft-tissue masses. Semin Roentgenol. 2010;45(4):277–97.

    Article  PubMed  Google Scholar 

  14. 14.

    van Rijswijk CS, Geirnaerdt MJ, Hogendoorn PC, Taminiau AH, van Coevorden F, Zwinderman AH, et al. Soft-tissue tumors: value of static and dynamic gadopentetate dimeglumine-enhanced MR imaging in prediction of malignancy. Radiology. 2004;233(2):493–502.

    Article  PubMed  Google Scholar 

  15. 15.

    Mirowitz SA, Totty WG, Lee JK. Characterization of musculoskeletal masses using dynamic Gd-DTPA enhanced spin-echo MRI. J Comput Assist Tomogr. 1992;16(1):120–5.

    CAS  PubMed  Google Scholar 

  16. 16.

    Fletcher BD, Hanna SL. Musculoskeletal neoplasms: dynamic Gd-DTPA-enhanced MR imaging. Radiology. 1990;177(1):287–8.

    CAS  PubMed  Google Scholar 

  17. 17.

    Persson BM, Rydholm A. Soft-tissue masses of the locomotor system. A guide to the clinical diagnosis of malignancy. Acta Orthop Scand. 1986;57(3):216–9.

    Article  CAS  PubMed  Google Scholar 

  18. 18.

    Khoo M, Pressney I, Hargunani R, Saifuddin A. Small, superficial, indeterminate soft-tissue lesions as suspected sarcomas: is primary excision biopsy suitable? Skelet Radiol. 2017;46(7):919–24.

    Article  Google Scholar 

  19. 19.

    Murphey MD, Gibson MS, Jennings BT, Crespo-Rodriguez AM, Fanburg-Smith J, Gajewski DA. From the archives of the AFIP: imaging of synovial sarcoma with radiologic-pathologic correlation. Radiographics. 2006;26(5):1543–65.

    Article  PubMed  Google Scholar 

  20. 20.

    Kransdorf MJ. Malignant soft-tissue tumors in a large referral population: distribution of diagnoses by age, sex, and location. AJR Am J Roentgenol. 1995;164(1):129–34.

    Article  CAS  PubMed  Google Scholar 

  21. 21.

    Calleja M, Dimigen M, Saifuddin A. MRI of superficial soft tissue masses: analysis of features useful in distinguishing between benign and malignant lesions. Skelet Radiol. 2012;41(12):1517–24.

    Article  Google Scholar 

  22. 22.

    Rydholm A. Management of patients with soft-tissue tumors. Strategy developed at a regional oncology center. Acta Orthop Scand Suppl. 1983;203:13–77.

    CAS  PubMed  Google Scholar 

  23. 23.

    Dyrop HB, Safwat A, Vedsted P, Maretty-Kongstad K, Hansen BH, Jorgensen PH, et al. Characteristics of 64 sarcoma patients referred to a sarcoma center after unplanned excision. J Surg Oncol. 2016;113(2):235–9.

    Article  PubMed  Google Scholar 

  24. 24.

    Grimer RJ. Size matters for sarcomas! Ann R Coll Surg Engl. 2006;88(6):519–24.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Myhre-Jensen O. A consecutive 7-year series of 1331 benign soft tissue tumours. Clinicopathologic data. Comparison with sarcomas. Acta Orthop Scand. 1981;52(3):287–93.

    Article  CAS  PubMed  Google Scholar 

  26. 26.

    Kransdorf MJ. Benign soft-tissue tumors in a large referral population: distribution of specific diagnoses by age, sex, and location. AJR Am J Roentgenol. 1995;164(2):395–402.

    Article  CAS  PubMed  Google Scholar 

  27. 27.

    Yoo HJ, Choi JA, Chung JH, Oh JH, Lee GK, Choi JY, et al. Angioleiomyoma in soft tissue of extremities: MRI findings. AJR Am J Roentgenol. 2009;192(6):W291–4.

    Article  PubMed  Google Scholar 

  28. 28.

    Beaman FD, Kransdorf MJ, Andrews TR, Murphey MD, Arcara LK, Keeling JH. Superficial soft-tissue masses: analysis, diagnosis, and differential considerations. Radiographics. 2007;27(2):509–23.

    Article  PubMed  Google Scholar 

  29. 29.

    Rowbotham E, Bhuva S, Gupta H, Robinson P. Assessment of referrals into the soft tissue sarcoma service: evaluation of imaging early in the pathway process. Sarcoma. 2012;2012:781723.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Ty K. Subhawong.

Ethics declarations

This study involving human subjects was performed in accordance with the ethical standards of the University of Miami Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of interest

Kevin Pham: No potential conflicts of interest to disclose.

Nisreen S. Ezuddin: No potential conflicts of interest to disclose.

Ty K. Subhawong MD has received honoraria from iiCME for speaking activities unrelated to preparation of this manuscript; he has served as a consultant for Agios Pharmaceuticals and Arog Pharmaceuticals but has received no funding for preparation of this manuscript.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Pham, K., Ezuddin, N.S., Pretell-Mazzini, J. et al. Small soft tissue masses indeterminate at imaging: histological diagnoses at a tertiary orthopedic oncology clinic. Skeletal Radiol 48, 1555–1563 (2019). https://doi.org/10.1007/s00256-019-03205-0

Download citation

Keywords

  • Soft tissue mass
  • Sarcoma
  • MRI
  • Ultrasound
  • Indeterminate