A. M. De Schepper (Editor)
P. M. Parizel 1. De BeuckeleerF. Vanhoenacker (Coeditors)
Imaging ofSoftTissue Tumors
Second Editionwith 354 Figures in 955 Separate Illustrationsand 32 Tables
Springer
Arthur M. De Schepper, MD, PhD - Professor and ChairmanPaul M. Parizel, MD, PhD - Staff RadiologistLuc De Beuckeleer, MD - RadiologistFilip Vanhoenacker, MD - Staff Radiologist
Department of Radiology, University Hospital of AntwerpWilrijkstraat 10,2650 Edegem, Belgium
Library of Congress Cataloging-in-Publication DataImaging of soft tissue tumors/A.M. De Schepper, editor; P.M. Parizel . . . [et a1. J,coeditors. -2nd ed.p.cm. Includes bibliographical references and index.I. Soft tissue tumors-Imaging. I. Schepper, A. M. De, 1937-. II. Parizel, P.M.(Paul M.), 1956-. RC280.S66143 2001 616.99'40754-dc21 2001020039
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Preface to the Second Edition
At the time of writing, our group has had more than 10years' experience in the imaging of soft tissue tumors. We are now, - more thanever, - convinced that a multidisciplinary dialogue between orthopedic surgeons, oncologists, pathologists and radiologists is imperativefor the medical management of these lesions. The common goals of allspecialists dealing with soft tissue tumors should be: early detection,minimally invasive staging and grading procedures, specific diagnosis(or suitably ordered differential diagnosis), guided percutaneous biopsies, and the most suitable therapy. This approach will guarantee thepatient the optimal chances of survival with the best possible quality oflife. To help us achieve these goals, we have established a Commissionfor Bone and Soft Tissue Tumors at the University Hospital in Antwerp,which convenes every 2 weeks. This multidisciplinary group formulates opinions and recommendations on diagnosis, prognosis, treatment and follow-up, and is highly valued by referring physicians. Inaddition, we are organizing a Belgian Registry of Soft Tissue Tumorswith the cooperation of all Belgian centers in which MRI equipment isavailable and intend to invite students and investigators from all overthe world to share our scientific interest in this fascinating field of medical imaging.
The main objective of this second edition of "Imagingof Soft TissueTumors"is to provide radiologists with an updated and easy-to- read reference work. This second edition includes new literature references and illustrations. Older illustrations have been replaced with higher qualityimages, generated by newer equipment and/or MRI pulse sequences.New tables organizing information into summaries have been includedand the subject index has been updated. Most importantly, the text contains newer insights (for instance about fibrohistiocytic tumors), and reflects our own experience of increasing understanding of soft tissue tumors and their imaging.The chapter about magnetic resonance imaginghas been shortened, and now focuses mainly on principles, pulse sequences and applications that are directly related to the examination ofsoft tissues and soft tissue tumors. We have included new chapters on"Soft Tissue Tumors in Pediatric Patients" and"Soft Tissue Lymphoma",and also a chapter on the controversial subject of (percutaneous) biopsy.
The readers and the reviewers of our book will judge whether wehave succeeded in our objectives.
Finally, we would like to thank our editor and Mrs. MenneckeBuhler at Springer-Verlag for sharing in the challenge of editing a second edition of this book on a rare pathology.
Antwerp, July 2001 Arthur M. De Schepper
Preface to the First Edition
Although the soft tissues constitute a large part of the human body, softtissue tumors are rare, accounting for less than 1% of all neoplasms.The annual incidence of benign soft tissue tumors in a hospital population is 300 per 100000. Moreover,benign lesions outnumber their malignant counterparts by about 100 to 1. The clinical and biochemicalfindings of soft tissue tumors are frequently nonspecific. The first signis usually a soft tissue swelling or a palpable mass with or without painor tenderness. Laboratory results are frequently normal or show minimal nonspecific changes.
Until a few decades ago, detection of soft tissue tumors usually didnot take place until late in the course of disease. This resulted fromtheir low incidence and nonspecific clinical findings and from the poorsensitivity of conventional radiography, which was the only imagingtechnique available.Soft tissue tumors and soft tissue disorders in general were practically unknown to radiologists until the introductionof ultrasound and computed tomography (CT). Unfortunately, thesemethods suffered from inherent drawbacks, such as the poor specificity of ultrasound and the poor contrast resolution of CT.
Many of these problems were solved by the introduction ofmagnetic resonance imaging (MRI). Thanks to its high contrast tissue resolution and its multiplanar imaging capability, new horizonswere opened for imaging soft tissues. Today, a correct assessment ofdisorders of bones, joints, or soft tissues is unimaginable withoutMRI.
In view of recent developments in surgery, radiation therapy, systemic chemotherapy, and regional perfusion techniques, the imagingof soft tissue tumors is gaining in importance. Correct diagnosis includes the detection, characterization, and staging of the lesions. Theinadequate diagnosis and therapy of soft tissue sarcomas frequentlyresults in tumor recurrence, necessitating major therapeutic "aggression." MRI is the optimal imaging technique for avoiding inadequateassessment.
Despite the interest of many groups of radiologists in the subjectand despite the considerable number of overview articles that havebeen published in the radiologic literature, soft tissue tumors receiveonly minimal attention in modern state-of-the-art books on musculoskeletal imaging . Nevertheless, since all radiologists involved in the fascinating field of MRI are now confronted with tumoral pathology ofsoft tissues, there is a need for an illustrated radiologic guide on thesubject.
From the beginning of our experience using MRI, back in 1985,wehave been interested in soft tissue tumors. Our initial findings were
VIII Preface to the FirstEdition
discussed at an international congress in 1992.Conflicting findings inthe literature concerning the sensitivity and specificity of MRI, whichwere mainly caused by the limited number of patients in published series, prompted us to start a multicenter European study. At the European Congress of Radiology 1993 in Vienna, 29 co-investigators from allover Europe agreed to participate (see the list 'Investigators of Multicentric European Study on Magnetic Resonance Imaging of Soft TissueTumors'). More than 1000cases were collected, which constitute the basis of the radiologic work we prepared.
It was not our intention to write the 'all you ever wanted to know'book on soft tissue tumors. This objective has already been achievedfor the pathology of soft tissue tumors by Enzinger and Weiss. Although their famous textbook contains a brief discussion of modernmedical imaging, you will find it rarely on the office desk of radiolo gists. This present book is intended to serve as a reference guide forpractising radiologists and clinicians seeking the optimal imaging approach for their patients with a soft tissue tumor.
The book is divided into four sections. In the first section we discussthe different imaging modalities and their respective contribution tothe diagnosis of soft tissue tumors. As MRI is generally accepted to bethe method of choice, there is a detailed theoretical description of thistechnique combined with a short discussion of imaging sequences. Wealso included a chapter on scintigraphy of soft tissue tumors, in whichthe current literature on the subject is summarized because scintigraphy was hardly used in our own patient material.
The second part deals with staging and characterization of softtissue tumors and is concluded by a chapter on general imaging strategy. Tumor-specific imaging strategy is, where needed, added at theend of the tumor-specific chapters, which are collected in Part III.These chapters include a short description of epidemiology, clinicaland pathological presentation, and a detailed discussion of imagingfindings . For this Part , we used the classification of E. B. Chung (Current classification of soft tissue tumors. In: Fletcher CD, McKee PH(eds) Pathobiology of soft tissue tumors, 1st edn. Churchill Livingstone, Edinburgh, 1990,pp 43-81), which is an updated version of themost comprehensive system of classification, that of the World HealthOrganization. Because the illustrations originate from differentinstitutions using different MR systems and pulse sequences, thefigure legends only mention the plane of imaging (sagittal, axial,coronal), the kind of sequence (SE,TSE, GRE,.. .), and the weighting(TI, T2).
The fourth part consists of only one chapter dealing with post -treatment imaging findings .
I would like to thank my co-editors Dr. Paul Parizel, Dr. Frank Ramon, Dr. Luc De Beuckeleer, and Dr. Jan Vandevenne, and all the coauthors for the tremendous job they have done . From this work Ilearned that writing a good book requires a sabaticcal leave, whichgood fortune I did not have.
As previously mentioned, it has been possible to include many of theillustrations shown in the book only because of the cooperation of the29 European investigators, to whom lowe my gratitude. We gratefullyacknowledge the support of Prof. Eric Van Marek, pathologist at our in-
Preface to the FirstEdition IX
stitution, for reviewing the manuscript, and of Ingrid Van der Heyden(secretary) for her aid in preparing so many chapters.
Finally, I wish to express my gratitude to Springer-Verlag and toDr. Ute Heilmann for sharing the challenge of preparing this book withus.
Antwerp, June 1996 Arthur M. De Schepper
Contents
Imaging Modalities .
1 Ultrasound of Soft Tissue TumorsR. Ceulemans and M. van Holsbeeck
2 Color Doppler UltrasonographyH.-J. van der Woude, K.1. Verstraete, and J.1. Bloem
3
21
3 Plain Radiography, Angiography, and Computed TomographyA. M. Davies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4 Nuclear Medicine ImagingP.P.Blockx and 1. Carp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5 Magnetic Resonance ImagingH. Bosmans, P. Brys, and G. Marchal 61
6 Dynamic Contrast-enhanced Magnetic Resonance ImagingK.L.Verstraete and H.-J. van der Woude 83
Staging, Characterization, and Grading . . . . . . . . . . . . . . . . . . . .. 105
7 StagingS.M. Levine, R. M. Terek, T.J.Hough, and G.A. Tung 107
8 Grading and Characterization of Soft Tissue TumorsA.M. De Schepper 123
9 General Imaging StrategyF.Ramon 143
Imaging ofSoftTissueTumors 147
10 Tumors of Fibrous TissueA.M. De Schepper and J. E.Vandevenne .. . . . . . . . . . . . . . . . . . 149
11 Fibrohistiocytic TumorsL.De Beuckeleer 181
XII Contents
12 Lipomatous TumorsM. C.Marques, H. Garcia, and F. Vanhoenacker 195
13 Tumors and Tumorlike Lesions of Blood VesselsF. Ramon 225
14 Lymphatic TumorsL. van den Hauwe and F. Ramo n . . . . . . . . . . . . . . . . . . . . . . . . . . 245
15 Tumors of Muscular OriginP. C.Seynaeve, L. L. Mortelmans, and A. M. De Schepper . . .. . 255
16 Synov ial Tumo rsF. Vanhoenacker, J.W. M.Van Goethem, J. E.Vandeve nne,and M. Shahabpo ur 273
17 Tumors of Peri ph eral NervesP. M. Parizel, W. A. Simoens, C.Mato s, and K. L.Verstraete ... 301
18 Extraskeletal Cartilaginous and Osseo us TumorsH. R. Degryse and F. Aparisi 331
19 Primitive Neuroectodermal Tumors and Related LesionsW. A.Simoens and H. R. Degryse . . . . . . . . . . . . . . . . . . . . . . . .. 353
20 Lesions of Uncertain OriginH. R. Degryse 363
21 Pseudotumoral LesionsR.Salgado, J. Alexiou, and J.-L. Engelholm . . . . . . . . . . . . . . . .. 387
22 Soft Tissue Metas tasi sJ. Alexiou, J. -L. Engelho lm, and L. De Beuckeleer . . . . . . . . . . . 413
23 Soft Tissue LymphomaP. Bracke, F. Vanhoenacker, and A. M. De Schep per 427
24 Soft Tissue Tumors in Pediatric PatientsA.M.De Schepper, L. De Beuckeleer,and J.E.Vandevenne . . . . 433
25 Biopsy of Soft Tissue TumorsA. M. De Schepper 447
Imaging AfterTreatment 453
26 MRI in the Follow-up of Malignantand Aggressive Soft Tissue TumorsD.Vanel, L. G. Shapeero, J.M. Guinebretiere, A. Lecesne,and J. Genin 455
Subjec t Ind ex 463
Contributors
Jean Alexiou, MDDepartment of Radiology, Institut BordetRue Heger-Border 1,1000 Brussels, Belgium
Francesco Aparisi, MDDepartment of Magnetic Resonance ImagingClinica Virgen del ConsueloCallosa de Ensarria 12,46007 Valencia, Spain
Pierre P.Blockx, MDDepartment of Nuclear Medicine, Universitair Ziekenhuis AntwerpenUniversity of AntwerpWilrijkstraat 10,2650 Edegem, Belgium
[ohan 1. Bloem, MD,PhDDepartment of Diagnostic Radiology and Nuclear MedicineLeiden University Hospital, Gebouw 1,C2-SPB 9600,2300 RC Leiden, The Netherlands
Hilde Bosmans, MD,PhDDepartment of Radiology, Universitair Ziekenhuizen LeuvenKatholieke Universiteit LeuvenHerestraat 49, 3000 Leuven, Belgium
Peter Bracke, MDDepartment of Radiology, KLINAAugustijnslei 100,2930 Brasschaat, Belgium
Peter Brys, MDDepartment of Radiology, Universitair Ziekenhuizen LeuvenKatholieke Universiteit LeuvenHerestraat 49,3000 Leuven, Belgium
Laurens Carp, MDDepartment of Nuclear Medicine, Universitair Ziekenhuis AntwerpenUniversity of AntwerpWilrijkstraat 10,2650 Edegem, Belgium
Ruth Ceulemans, MDDepartment of Diagnostic Radiology and Nuclear MedicineLeiden University Hospital, Gebouw 1,C2-SPB 9600,2300 RC Leiden, The Netherlands
XIV Contributors
A. Mark Davies, MB, ChB, DMRD, FRCRMRI Centre, Royal Orthopaedic HospitalThe Woodlands, Bristol Road SouthBirmingham B 31 2AP,UK
Luc De Beuckeleer, MDDepartment of Radiology, Sint Augustinus Ziekenhuis, WilrijkUniversitair Ziekenhuis AntwerpenUniversity of AntwerpWilrijkstraat 10,2650 Edegem, Belgium
Arthur M. De Schepper, MD, PhDDepartment of Radiology, Universitair Ziekenhuis AntwerpenUniversity of AntwerpWilrijkstraat 10,2650 Edegem, Belgium
Hendrik R. Degryse, MDDepartment of Radiology, KLINA,Brasschaat,Universitair Ziekenhuis AntwerpenUniversity of AntwerpWilrijkstraat 10,2650 Edegem, Belgium
Iean-Luc Engelholm,MDDepartment of Radiology, Institut BordetRue Heger-Border 1,1000 Brussels, Belgium
Helena Garcia, MDDepartment of Pathology, Hospitais da Universidade de CoimbraPrac. Prof. Mota Pinto, 3000 Coimbra, Portugal
J.Genin,MDDepartment of Surgery, Institut Gustave-RoussyRue Camille Desmoulins, 94805 Villejuif, France
J.M. Guinebretiere, MDDepartment of Pathology, Institut Gustave-RoussyRue Camille Desmoulins, 94805 Villejuif, France
Timothy J. Hough, MDDepartment of Diagnostic Imaging, Rhode Island HospitalBrown University School of Medicine593 Eddy Street, Providence, RI 02093, USA
A. Lecesne, MDDepartment of Radiology, Institut Gustave-RoussyRue Camille Desmoulins, 94805 Villejuif, France
Scott M. Levine, MDDepartment of Diagnostic Imaging, Rhode Island HospitalBrown University School of Medicine593 Eddy Street, Providence, RI 02093, USA
Contributors XV
Guy Marchal, MD, PhDDepartment of Radiology, Universitair Ziekenhuizen LeuvenKatholieke Universiteit LeuvenHerestraat 49, 3000 Leuven, Belgium
M. Cristina Marques, MDDepartment of Radiology, Hospitais da Universidade de CoimbraPrac. Prof. Mota Pinto, 3000 Coimbra, Portugal
Celso Matos , MDDepartment of Radiology, Hopital ErasmeUniversite Libre de BruxellesRoute de Lennik 808,1070 Brussels, Belgium
Lieven 1. Mortelmans, MDDepartment of Diagnostic RadiologyAlgemeen Ziekenhuis MiddelheimLindendreef 1,2020 Antwerp, Belgium
Paul M. Parizel, MD, PhDDepartment of Radiology, Universitair Ziekenhuis AntwerpenUniversity of AntwerpWilrijkstraat 10,2650 Edegem, Belgium
Frank Ramon, MDDepartment of Radiology, Algemeen Ziekenhuis Maria MiddelaresHospitaalstraat 17,9100 St.-Niklaas, Belgium
Rodrigo Salgado, MDDepartment of Radiology, Universitair Ziekenhuis AntwerpenUniversity of AntwerpWilrijkstraat 10,2650 Edegem, Belgium
Patrick C.Seynaeve, MDDepartment of Diagnostic Radiology, MR Unit CAZK GroeningheLoofstraat 43, 8500 Kortrijk, Belgium
Maryam Shahabpour, MDDepartment of Diagnostic RadiologyAcademisch Ziekenhuis Vrije Universiteit BrusselLaarbeeklaan 101,1090 Brussels, Belgium
L.G. Shapeero, MDDepartment of RadiologyUniformed Services University of the Health SciencesBethesda
William A. Simoens, MDDepartment of Radiology, Universitair Ziekenhuis AntwerpenUniversity of AntwerpWilri jkstraat 10,2650 Edegem, Belgium
XVI Contributors
Richard M. Terek, MDDepartment of Orthopedic Surgery, Rhode Island HospitalBrown University School of Medicine593 Eddy Street, Providence, RI 02093, USA
Glenn A. Tung, MDDepartment of Diagnostic Imaging, Rhode Island HospitalBrown University School of Medicine593 Eddy Street, Providence, RI 02093, USA
Luc van den Hauwe, MDDepartment of Radiology,KLINA,Brasschaat,Universitair Ziekenhuis AntwerpenUniversity of AntwerpWilrijkstraat 10,2650 Edegem, Belgium
Henk-Jan van der Woude, MD, PhDDepartment of Diagnostic Radiology and Nuclear MedicineLeiden University Hospital, Gebouw 1,C2-SPB 9600,2300 RC Leiden, The Netherlands
Iohan W.M.Van Goethem, MD, PhDDepartment of Radiology,Algemeen Ziekenhuis Maria Middelares, St NiklaasUniversitair Ziekenhuis Antwerpen, University of AntwerpWilrijkstraat 10,2650 Edegem, Belgium
Marnix van Holsbeeck, MDDepartment of Diagnostic RadiologySection Musculoskeletal Radiology and Emergency RadiologyHenry Ford Hospital2799 West Grand Boulevard, Detroit, MI 48202-2689, USA
Jan E.Vandevenne, MDDepartment of Radiology, St.-Jan GenkSchiepse Bos 6,3600 Genk, Belgium
Daniel Vanel, MDDepartment of Radiology, Institut Gustave- RoussyRue Camille Desmoulins, 94805 Villejuif, France
F.Vanhoenacker, MDDepartment of Radiology, Algemeen Ziekenhuis S1. Maarten,Duffel-Mechelen, Department of Radiology,Universitair Ziekenhuis Antwerpen, University of Antwerp,Wilrijkstraat 10,2650 Edegem, Belgium
Koenraad L. Verstraete, MD, PhDDepartment of Radiology, Universitair Ziekenhuis GentUniversity of GhentDe Pintelaan 185,9000 Ghent, Belgium