Angiomatoid fibrous histiocytoma: novel MR imaging findings.

OBJECTIVE: To describe novel MR imaging features, and clinical characteristics of soft tissue angiomatoid fibrous histiocytoma (AFH) at presentation, local recurrence, and metastases. MATERIALS AND METHODS: We described the MRI findings of six cases of histologically proven AFH. Pathologic findings, clinical presentation, and outcome were reviewed. RESULTS: Lesions were primarily cystic. At initial presentation, tumors were surrounded by low signal intensity fibrous pseudocapsule. High signal intensity consistent with the lymphoplasmacytic infiltrate was seen in T2-weighted and post-contrast images as a rim over the hypointense pseudocapsule (double rim sign). High signal intensity infiltrating tumoral cords extended into adjacent tissues, through pseudocapsular defects on T2-weighted and post-contrast images. The cystic component and tumor cell nodularity were demonstrated at post-contrast images. Clinically, lesions were often thought to be benign, underwent marginal resection, developed local recurrence, and one developed second recurrence consisting of metastases. Recurrent tumors appeared as multiple masses, misinterpreted as post-surgical changes. An intramuscular recurrence demonstrated double rim and infiltrating margin. CONCLUSIONS: A predominantly well-circumscribed, primarily cystic mass with double-rim and marginal infiltration on MRI suggests the possibility of AFH, in particular in child or young adult. Inclusion of these novel observations in AFH differential diagnosis may have a significant impact on treatment and prevention of recurrence.

Imaging of recurrent intramuscular granulomatous masses induced by depot injection of leuprorelin.

Leuprorelin is a luteinizing hormone-releasing hormone (LH-RH) agonist that is used as an agent of androgen deprivation in some patients with prostate cancer. When administered in depot form, local granulomatous reactions may occur at the injection site, which may mimic masses and which are associated with treatment failure. We present a patient who, over a period of 5 years, developed multiple intramuscular gluteal masses while receiving leuprorelin therapy via intramuscular depot injections; biopsy of one of the masses showed the specific histologic features of leuprorelin granuloma. To our knowledge, this entity has not been described in the radiology literature. Awareness of this entity is necessary to suggest the correct diagnosis in patients with a history of leuprorelin depot injections.

Extremity soft tissue sarcomas presented as hematomas.

INTRODUCTION: Soft tissue sarcoma (STS) with extensive intra-tumoral hemorrhage is an infrequently described entity, usually misdiagnosed as intra-muscular hematoma. The outcomes in this group of patients have not been previously described. MATERIALS AND METHODS: We retrospectively identified 15 patients, with initial clinical or imaging diagnosis of hematoma, or hematoma versus hemorrhagic sarcoma, although final diagnosis of high-grade STS was established in all cases. RESULTS: The most common location was the thigh. Three patients had a bleeding predisposition. Ten patients were referred for further evaluation with the initial diagnosis of muscle strain/hematoma, hematoma versus abscess in one, whereas four were referred for soft tissue mass evaluation. Final diagnosis was made by one biopsy in only 53% of patients. Mean time to diagnosis for patients with two biopsies was 7 months from initial presentation. Histologic diagnosis was malignant fibrous histiocytoma in ten patients. Surgical treatment included tumor resection in eleven and amputation in three patients. One patient had lung metastatic disease at presentation and eight developed lung metastases within a median time of 7 months. CONCLUSION: We suggest that an STS masquerading as hematoma should be suspected when the mechanism and the energy of the trauma do not justify the clinically detected severity of the injury, or the lesion does not follow the expected clinical course of resolution after initial conservative management. Bleeding predisposition does not exclude malignancy. The evacuation of hematomas should include pathologic examination of tissue. Prognosis is dismal due to early metastatic disease.

The clinical management of chondrosarcoma.

OPINION STATEMENT: Chondrosarcomas (CHS) represent a heterogeneous group of disorders ranging from indolent, low-grade tumors to aggressive, high-grade forms. Surgical resection represents the primary and preferred treatment modality for individuals with localized disease. Radiation therapy is appropriate for the treatment of positive surgical margins or palliation of disease-related symptoms. The treatment of advanced, metastatic disease is particularly challenging given the recognition that conventional chemotherapy has proven to be largely ineffective. Systemic chemotherapy may be considered in variant forms such as mesenchymal or dedifferentiated chondrosarcomas but high-quality data supporting its use is limited. There is universal agreement, however, that novel treatment strategies are desperately needed. This review will highlight the need for a coordinated multidisciplinary approach to optimize the management and care of patients.

Synovial lipomatosis arborescens of the peroneal tendon sheath.

The term "lipoma arborescens" has been used to describe the diffuse infiltration of fat within hypertrophic synovial villi, a condition which has been most frequently described in the knee. We advocate the term "synovial lipomatosis arborescens" for this process and present what is, to our knowledge, the first reported case of this disorder isolated to the peroneal tendon sheath, with imaging, intraoperative, and histological correlation.

Simultaneous thigh muscle metastasis from lung cancer and Escherichia coli gas producing myonecrosis.

We present the case of a 41-year-old man with known large cell lung cancer who had undergone left pneumonectomy 7 months prior and who presented with a large intramuscular mass involving the posterior left thigh and upper calf. This thigh mass was ultimately surgically explored, and specimens yielded both Escherichia coli organisms and cells reflecting a skeletal muscle metastasis from the patient's known lung cancer. The patient was also found to have a rectal metastasis from his lung cancer. Intramuscular abscesses produced by gastrointestinal tract flora are a well-known presentation of colon cancer. To our knowledge, this is the first case report of the simultaneous occurrence of a skeletal muscle metastasis and an E. coli abscess in the same anatomic location. We believe the patient's rectal metastasis may have been the intermediate step in this process.

Fibrogenesis imperfecta ossium: MR imaging of the axial and appendicular skeleton and correlation with a unique radiographic appearance.

We describe a distinctly unusual MR appearance of the cancellous bone never before described in a patient with biopsy-proven fibrogenesis imperfecta ossium.

Acral myxoinflammatory fibroblastic sarcomas: MRI findings in four cases.

OBJECTIVE: Acral myxoinflammatory fibroblastic sarcoma is a rare, recently described, low-grade sarcoma that involves mainly the distal extremities. The purpose of this study is to report the MRI findings in four cases of acral myxoinflammatory fibroblastic sarcoma. CONCLUSION: Acral myxoinflammatory fibroblastic sarcomas may present with various MRI patterns that probably reflect their variable histologic composition. Differential diagnosis with other benign conditions, especially with ganglion cysts and giant cell tumors of the tendon sheath, may be difficult. We report tumoral invasion of the bone in one case, which to our knowledge has not been previously described.

Soft-tissue tumors update: MR imaging features according to the WHO classification.

Soft-tissue tumors are a large and heterogeneous group of neoplasms. Hence, classification is often difficult. The most effective management decisions are made when a working group participates in the same diagnostic standard criteria in the evaluation of soft-tissue tumors. The purpose of this pictorial review is to highlight the new and the less well-known features on magnetic resonance (MR) imaging of soft-tissue tumors according to the World Health Organization (WHO) classification established in 2002. The article depicts the major changes of the WHO classification since it was established in 2002 and the most significant findings on MR imaging, thereby providing an update.

Neuropsychological assessment, neuroimaging, and neuropsychiatric evaluation in pediatric and adult patients with sickle cell disease (SCD).

Traditionally, neuropsychological deficits due to Sickle Cell Disease (SCD) have been understudied in adults. We have begun to suspect, however, that symptomatic and asymptomatic Cerebrovascular Events (CVE) may account for an alarming number of deficits in this population. In the current brief review, we critically evaluated the pediatric and adult literatures on the neurocognitive effects of SCD. We highlighted the studies that have been published on this topic and posit that early detection of CVE via neurocognitive testing, neuropsychiatric evaluations, and neuroimaging may significantly reduce adult cognitive and functional morbidities.

Case reports: acral myxoinflammatory fibroblastic sarcoma: a report of five cases and literature review.

During the past 2 years, we treated five patients with acral myxoinflammatory fibroblastic sarcoma at our institution. Four patients presented with a firm, painless mass in the hand that appeared over several months. One patient discovered a painless mass in his shoulder region. The five patients initially were diagnosed as having benign conditions and treated with intralesional or marginal excision by referring physicians, only to have the lesion reappear as sarcoma. Each patient was treated with wide resection of the tumor bed. Acral myxoinflammatory fibroblastic sarcoma is a rare, but increasingly recognized sarcoma of the distal extremities, which often is confused with benign lesions. Surgeons should be familiar with this tumor's clinical, radiographic, and histologic appearances as it has a high rate of recurrence and can metastasize.

Group treatment improves trunk strength and psychological status in older women with vertebral fractures: results of a randomized, clinical trial.

OBJECTIVES: To assess whether group exercise and coping classes reduce physical and psychological impairments and functional disability in older women with prevalent vertebral fractures (VFs). DESIGN: Randomized, controlled trial (modified cross-over) with site as unit of assignment; testing at baseline and 3, 6, 9, and 12 months. SETTING: Nine North Carolina retirement communities. PARTICIPANTS: One hundred eighty-five postmenopausal Caucasian women (mean age 81), each with at least one VFs. INTERVENTION: The intervention group had 6 months of exercise (3 meetings weekly, 45 minutes each) and coping classes (2 meetings weekly, 45 minutes each) in Phase 1, followed by 6 months of self-maintenance. The control group had 6 months of health education control intervention (1 meeting weekly, 45 minutes) in Phase 1, followed by the intervention described above. MEASUREMENTS: Change in trunk extension strength, change in pain with activities, and change in psychological symptoms. RESULTS: Between-group differences in the change in trunk extension strength (10.68 foot pounds, P<.001) and psychological symptoms (-0.08, P=.011) were significant for Phase 1. Changes in pain with activities did not differ between groups (-0.03, P=.64); there was no change in the pain endpoint. In Phase 2, controls showed significant changes in trunk strength (15.02 foot pounds, P<.001) and psychological symptoms (-0.11, P=.006) from baseline. Change in pain with activities was not significant (-0.03, P=.70). During self-maintenance, the intervention group did not worsen in psychological symptoms, but improved trunk extension strength was not maintained. CONCLUSION: Weak trunk extension strength and psychological symptoms associated with VFs can be improved in older women using group treatment, and psychological improvements are retained for at least 6 months.

Giant cell tumor of rib masquerading as thymoma: a diagnostic pitfall in needle core biopsy of the mediastinum.

Giant cell tumor of bone is rarely seen in the rib, where it may present as a mediastinal mass. The diagnosis of giant cell tumor of bone is generally straightforward by fine-needle aspiration or needle core biopsy, but sampling problems may lead to confusion with other neoplasms or inflammatory processes. Here, we report a case of giant cell tumor of rib presenting as a mediastinal mass in a 36-year-old man. Because of inadequate sampling and inaccurate clinical information, the tumor was initially mistaken for thymoma. When the mass failed to respond to conventional chemotherapy, additional tissue was obtained and a giant cell tumor was diagnosed. Consequently, definitive therapy was delayed. The case illustrates an important diagnostic pitfall in the biopsy of mediastinal masses.

Tumoral calcinosis: 12 years later.

During the last 12 years, tumoral calcinosis (TC) has become an entity that is better understood by radiologists, clinicians, and pathologists. Several aspects of TC are well documented by the scientific community, although the most important, etiology, remains an enigma. As a consequence, the treatment of TC continues to be symptomatic. Imaging continues to be the best method for diagnosis, assessing extension, evaluating complications, monitoring treatment, and selecting patients for surgical excision. Investigators from different countries are reporting the most elusive component of TC: calcific myelitis. New systemic and cerebrovascular complications, even in the young, have been described recently. Similarly, ocular manifestation, which had not been reported previously, is well described in the recent literature. A few, poorly documented reports are confounding TC myelitis with osteomyelitis and TC periarticular soft tissue masses with tumoral calcium pyrophosphate dihydrate (CPPD) of the temporomandibular joint and spine. Advances in the clinical arena have resulted in a new approach and classification of several clinical forms of TC. Most of the recent literature has been related to the histopathology of TC. A new view of the old "traumatic theory" suggests microtrauma of connective tissues around the joints, causing bleeding and the formation of rudimentary bursae as the initial event. Perhaps, in the near future, research will define at the genetic and molecular levels the etiology and pathophysiology that will allow the treatment and prevention of TC.

Analyzing pain in rheumatoid arthritis patients. Pain coping strategies in patients who have had knee replacement surgery.

This study used the Coping Strategies Questionnaire (CSQ) to investigate pain coping strategies in 52 rheumatoid arthritis patients who reported having knee pain 1 year or more following knee replacement surgery. Data analysis revealed that, as a group, these patients were active copers in that they reported frequent use of a variety of pain coping strategies. Pain coping strategies were found to be related to measures of pain and adjustment. Patients who rated their ability to control and decrease pain high and who rarely engaged in catastrophizing (i.e., who scored high on the Pain Control and Rational Thinking factor of the CSQ) had much lower levels of pain and psychological disability than patients who did not. Coping strategies were not found to relate to age, gender, obesity status or disability/compensation status. Taken together, these results suggest that an analysis of pain coping strategies may be helpful in understanding pain in arthritis patients who have pain following joint replacement surgery.

Osteoarthritic knee pain: a behavioral analysis.

This study used behavioral assessment techniques to analyze pain in osteoarthritis (OA) patients. Eighty-seven OA patients having chronic knee pain served as subjects. Pain behavior was evaluated using a standard observation method and functional impairment was assessed using the Arthritis Impact Measurement Scales. Data analysis revealed that pain and limitations in physical activities were the most common functional impairments and that the most frequently observed pain behavior was guarded movement. Predictive analyses indicated that disability support status and scores on a Pain Control and Rational Thinking factor of the Coping Strategies Questionnaire (CSQ) were predictive of functional impairment. Patients receiving disability support payments were much more functionally limited than those not receiving this financial support. Patients scoring high on the Pain Control and Rational Thinking factor of the CSQ were much less functionally impaired, walked a 5 m course more rapidly and moved from a standing to a sitting or reclining position more quickly than patients scoring low on this factor. The implications of these results for behavioral treatment of OA knee pain are discussed.