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Title : Case 129

Age / Sex : 35 / F



Age / Sex : 35/F


Chief complaint : RT.knee pain, duration : 1yr


                          Trauma hx (-)





1) What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

* Send Application Answers to Ja-Young Choi, MD ([email protected])

Courtesy: Kyu-Sung Kwack, MD., Ajou University Hospital


Diagnosis:

ossifying hemangioma



Discussion


Findings:


            


Plain X-ray
              Ossified mass with Swiss cheese appearance posteromedial to the distal femur.


             MRI


 About 2x2cm in transverse dimension and about 4cm in longitudinal dimension mass lesion at distal thigh posteromedial aspect. The lesion is located in the deep to the semimembranosus muscle. The mass showed heterogenous intermediate signal intensity on T1WI, heterogenous high signal intensity on T2WI. The inner very low signal intensity on T1WI & T2WI corresponded to the irregular radiopaque densities on the plain radiographs.


Enhanced sagittal T1WI shows heterogenous enhancement.


 


 


Differential Diagnosis:


1.     Myositis ossificans


2.     Extraskeletal osteosarcoma


3.     Synovial sarcoma


 


Diagnosis:  Intramuscular hemangioma with ossification



Discussion:


Only about 1% of hemangiomas originate in the skeletal muscle.


Benign soft tissue tumors, predominantly involve the large muscles of the thigh.


Highest prevalence in young women, in the 3rd decade of life.


Size : vary from less than 4cm to greater than 20cm, less than 9cm (m/c).


Components : Vascular components, thrombus, calcifications, hemosiderin, fat, smooth muscle, and fibrous tissue, mature bone (extremely rare)


 


Findings


X-ray :


Swiss cheese appearance, reflects architecture of mature bone interspersed with large cavernous vascular channels.


MRI :


intermediate signal intensity with a fairly well-delineated margin on T1WI
             and high signal intensity on T2WI. Heterogeneous signal intensity and a
             serpentine pattern. Contrast-enhanced MRI shows serpentine or latticelike
             enhancement of the lesions


 


             Low signal intensity on T1WI and T2WI can be caused byphleboliths,
            calcifications, ossification, or fibrosis. Although phleboliths in soft tissue
            hemangiomas are located within a thrombus of dilated vascular channels,
            ossification in soft tissue hemangiomas occurs within the fibrous stoma
            between the dilated vascular channels. The presence of phleboliths can be
            suggested when the low-intensity spot is located in enhanced vascular
            channels, and ossification can be diagnosed in the presence of an inner
            marrow signal. Additionally, the fibrotic change shows low signal intensity
            on  T1WI and T2WI with mild enhancement.



References:

 Intramuscular hemangioma with ossification, Ultrasound in Medicine • J Ultrasound Med 2008; 27:281–285

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Total Applicants (9)
Correct Answer (1)
박상현: 순천향대학천안병원(전공의)

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