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Calcified soft tissue leiomyoma of the shoulder mimicking a chondrogenic tumor
ELSEVIER
CALCIFIED SOFT TISSUE LEIOMYOMA OF THE SHOULDER MIMICKING A CHONDROGENIC TUMOR EDWARD H. DE MOUY, RAOUL p. RODRIGUEZ,
MD, MD
KUNIYUKI KANEKO,
A case of leiomyoma with prominent calcification in the deep soft tissue of the shoulder is reported. The tumor showed mulberry-like calcifications on mdiogmphs and computed tomogmphy scans. Magnetic resonance imaging (MRI) showed well-circumscribed solid tumor with multiple signal voids. Although the signal intensity characteristics of the tumor matrix on plain MRI resembled those of chondroid matrix, the entire tumor was enhanced by gadopentetote dimeglumine and could be differentiated from chondrogenic tumors. MRI was also useful in evaluating the tumor extent. KEY WORDS:
Leiomyoma;Calcification; Magnetic resonance imaging; Gadopentetatedimeglumine
INTRODUCI’ION Leiomyomas of the deep soft tissue in extremities are rare; only sporadic cases have been reported in the literature (1, 2). However, leiomyomas of deep soft tissue can develop calcifications (3-6) and differentiation from bone tumors is sometimes problematic using radiographic examinations. We present a case of calcified leiomyoma in the muscle of the shoulder, which showed interesting findings on magnetic resonance imagings (MRIs).
MD,
AND
(IASE REPORT A V-year-old girl with a left shoulder mass presented because of pain in the mass after a fall. Physical examination revealed a hard, slightly tender mass in the infraspinous region. Hemogram and results of all other laboratory studies were within normal limits. Plain radiographs showed prominent mulberry-like calcifications within the soft tissue mass (Figure 1); no bony change was appreciated. Computed tomography (CT) showed conglomerate calcifications within the left infraspinous muscle (Figure 2); however, the margin of the tumor was not clear because its density was similar to that of surrounding muscles and artifacts. T1weighted spin-echo (TR 40O/TEV) MI& demonstrated a well-circumscribed, low-intensity mass with multiple signal voids in the left infraspinous muscle (Figure 3A). The mass appeared as high-intensity signal on gradient-recalled acquisition in the steady state (GRASS) (TR 500/TE ll/flip angle 15‘9 images (Figure 3B), and showed homogeneous enhancement on postcontrast m-weighted images using gadopentetate dimeglumine (0.1 mmolkg) (Figure 3C). An operative procedure was performed for,removal of the mass. On cut section, a well-circumscribed white-to-tan nodule measuring 5 cm was noted. Microscopic examination of the tumor revealed sheets.of spindle cells with multiple zones of calcifications and confirmed the diagnosis of leiomyoma. DISCUSSION
From the Departments of Radiology (E.H.De M., K.K.) and Orthopedic Surgery (R.P.R.), Tulane University Medical Center, New Orleans, Louisiana. Address reprints requests to: Edward H. De Mouy, MD, Department of Radiology, Tulane University Medical Center, 1430 Tulane Avenue, New Orleans, LA 70112-2699. Received September 1, 1993; accepted December 1, 1993. CLINICAL IMAGING 1995;19:4-7 8 Elsevier Science Inc., 1995 655 Avenue of the Americas, New York, NY 10010
Leiomyomas of deep soft tissue are located in the deep muscles of the extremities and are believed to arise from smooth muscles of small blood vessels (1). Although this tumor is uncommon, many of them are calcified (3-6) and can be detected radiographically. These calcifications result from regressive changes in 0899-7071/95/$9.50
SSDI
0899-7cv1(94)ooom2
JANUARY-MARCH
1995
CALCIFIC SOFT TISSUE
LEIOMYOMA
OF THE SHOULDER
5
FIGURE 1. Anteroposterior radiograph of the left shoulder shows prominent mulberry-like calcifications. No bony change is seen. large tumors, and calcium is usually laid down in district spherules reminiscent of psammoma bodies (1). Sometimes the calcification is characteristic of that seen in uterine leiomyomas (3-6). ln our patient, the most particular radiographic finding was these calcifications. These calcifications may lead to diagnoses such as tumoral calcinosis, myositis ossificans, chonclrosarcoma, chonclroma, synovial sarcoma, or calcifying neurilemmoma. Radiographs of tumoral calcinosis (Figure 4) reveal circular or oval
B
FIGURE 2. Axial CT scan of the left shoulder demonstrates a soft tissue tumor with conglomerate calcifications.
C FIGURE 3. MRI of the left shoulder. (A) Coronal ‘I% weighted image shows low-intensity tumor with signal void. (B) Axial ‘IPweighted image shows high-intensity tumor with signal voids. (Cl Coronal enhanced ‘IX-weighted image shows homogeneous enhancement of the tumor matrix.
6
DE MOW
CLINICAL IMAGING VOL. 19, NO. 1
ET AL.
Synovial sarcoma. Anteroposterior radiograph 6. of the left forearm shows scattered irregular calcification (arrows) within the soft tissue mass. FIGURE
FIGURE
4. Tumoral calcinosis. Antemposterior radiograph of the left foot shows extremely dense multiloculated calcifications around the fifth metatarsophalangeal joint.
well-demarcated masses of calcium about articulations. A lobulated inbomogeneous appearance is characteristic (7). In addition, tumoral calcinosis usually does not show a soft tissue component on CT or MRI (8), and can be differentiated using these modalities. Myositis ossificans (Figure 5) can be differentiated by recognizing the trabecular pattern within the dense
5. Myositis ossificans. Anteroposterior radiograph of the elbow shows shell-like calcification along the midshaft of the humerus (arrow). A radiolucent zone is noted between the calcification and the bony cortex.
FIGURE 7. Chondrosarcoma. Anteroposterior radiograph of the left shoulder shows stippled and irregular calcifications around the proximal humeral metaphysis (arrow).
FIGURE
JANUARY -MARCH
1995
CALCIFIC SOFT TISSUE
areas of calcifications and its conformity to the muscle plane (7,9). Synovial sarcomas (Figure 6) frequently calcify (10, 11); however, the calcifications are usually scattered and irregular, and cortical erosions are also noted. Although neurilemmomas can calcify due to degenerative changes, the calcifications are very rare (7). It would appear that chondrogenic tumors presented the greatest problem of differential diagnosis in our patient, since the pattern of calcifications resembled that of chondrogenic tumors (chondroma or welldifferentiated chondrosarcoma) (Figure 7), and the signals for tumor matrix on plain MRI also were similar to those for chondroid matrix. However,these chondrogenie tumors usually show rim or arc enhancement (12, 13) and could be differentiated using enhanced MRI. To our knowledge, this is the first report of a soft tissue leiomyoma with prominent calcifications arising during late childhood, that also provides MRI evaluation of the lesion. Although the MRI findings were not specific to leiomyoma, MRI was more helpful than CT in defining the tumor extent and analyzing the tumor pathology. REFERENCES I. Enzinger FM, Weiss SW (eds): Soft Tissue Tumors, 2nd ed. St. Louis: CV Mosby, 1988.
LEIOMYOMA
OF THE SHOULDER
7
2. Yanopoulos K, Stout AP. Smooth muscle tumors in children. Cancer 1962;15:958-971. 3. Ledesma-Medina J, Oh KS, Girdany BR. Calcification hood leiomyoma. Radiology 1980;135:339-341.
in child-
4. Ross LS, Ecstein MR, Hirschhorm R, Khapra AH, Shylman S, Hochstim RJ. Calcified leiomyoma: an unusual cause of large soft-tissue calcification of calf in childhood. NY State J Med 1983;83:747-749. 5. Lubbers PR, Chandra R, Markle BM, Downey EF. Case report 421:calcified leiomyoma of the soft tissue of the right buttock. Skeletal Radio1 1987;16:252-256. 6. Herrhin K, Willen H, Rydholm A. Deep-seated soft tissue leiomyomas: report of four patients. Skeletal Radio1 1996; 19:363-365. 7. Resnick D, Niwayama G (eds): Diagnosis of Bone and Joint Disease, 2nd ed. Philadelphia: WB Saunders, 1988. 8. Martinez S, Vogler JB III, Harrelson JM, Lyles KW. Imaging of tumoral calcinosis: new observations. Radiology 1990;174: 215-222. 9. Samuelson KM, Coleman SS. Non-traumatic myositis ossificans in healthy individuals. JAMA 1976;235:1132-1133. 10. Varela-Duran J, Enzinger FM. Calcifying synovial sarcoma. Cancer 1982;50:343-352. 11. Wright PH, Sim FH, Soule EH, Taylor WF. Synovial J Bone Joint Surg [Am] 1982;64:112-122.
sarcoma.
12. Aoki J, Sone S, Fujioka F, et al. MR of enchondroma and chondrosarcoma: ring and arcs of Gd-DTPA enhancement. J Comput Assist Tomogr 1989;15:1011-1016. 13. Geirnaerdt MJA, Bloem JL, Euldevink F, Hogendoorn PCW, Taminiau AHM. Cartilaginous tumors: correlation of gadolinium-enhanced MR imaging and histopathologic findings. Radiology 1993;186:813-817.
CALCIFIED SOFT TISSUE LEIOMYOMA OF THE SHOULDER MIMICKING A CHONDROGENIC TUMOR EDWARD H. DE MOUY, RAOUL p. RODRIGUEZ,
MD, MD
KUNIYUKI KANEKO,
A case of leiomyoma with prominent calcification in the deep soft tissue of the shoulder is reported. The tumor showed mulberry-like calcifications on mdiogmphs and computed tomogmphy scans. Magnetic resonance imaging (MRI) showed well-circumscribed solid tumor with multiple signal voids. Although the signal intensity characteristics of the tumor matrix on plain MRI resembled those of chondroid matrix, the entire tumor was enhanced by gadopentetote dimeglumine and could be differentiated from chondrogenic tumors. MRI was also useful in evaluating the tumor extent. KEY WORDS:
Leiomyoma;Calcification; Magnetic resonance imaging; Gadopentetatedimeglumine
INTRODUCI’ION Leiomyomas of the deep soft tissue in extremities are rare; only sporadic cases have been reported in the literature (1, 2). However, leiomyomas of deep soft tissue can develop calcifications (3-6) and differentiation from bone tumors is sometimes problematic using radiographic examinations. We present a case of calcified leiomyoma in the muscle of the shoulder, which showed interesting findings on magnetic resonance imagings (MRIs).
MD,
AND
(IASE REPORT A V-year-old girl with a left shoulder mass presented because of pain in the mass after a fall. Physical examination revealed a hard, slightly tender mass in the infraspinous region. Hemogram and results of all other laboratory studies were within normal limits. Plain radiographs showed prominent mulberry-like calcifications within the soft tissue mass (Figure 1); no bony change was appreciated. Computed tomography (CT) showed conglomerate calcifications within the left infraspinous muscle (Figure 2); however, the margin of the tumor was not clear because its density was similar to that of surrounding muscles and artifacts. T1weighted spin-echo (TR 40O/TEV) MI& demonstrated a well-circumscribed, low-intensity mass with multiple signal voids in the left infraspinous muscle (Figure 3A). The mass appeared as high-intensity signal on gradient-recalled acquisition in the steady state (GRASS) (TR 500/TE ll/flip angle 15‘9 images (Figure 3B), and showed homogeneous enhancement on postcontrast m-weighted images using gadopentetate dimeglumine (0.1 mmolkg) (Figure 3C). An operative procedure was performed for,removal of the mass. On cut section, a well-circumscribed white-to-tan nodule measuring 5 cm was noted. Microscopic examination of the tumor revealed sheets.of spindle cells with multiple zones of calcifications and confirmed the diagnosis of leiomyoma. DISCUSSION
From the Departments of Radiology (E.H.De M., K.K.) and Orthopedic Surgery (R.P.R.), Tulane University Medical Center, New Orleans, Louisiana. Address reprints requests to: Edward H. De Mouy, MD, Department of Radiology, Tulane University Medical Center, 1430 Tulane Avenue, New Orleans, LA 70112-2699. Received September 1, 1993; accepted December 1, 1993. CLINICAL IMAGING 1995;19:4-7 8 Elsevier Science Inc., 1995 655 Avenue of the Americas, New York, NY 10010
Leiomyomas of deep soft tissue are located in the deep muscles of the extremities and are believed to arise from smooth muscles of small blood vessels (1). Although this tumor is uncommon, many of them are calcified (3-6) and can be detected radiographically. These calcifications result from regressive changes in 0899-7071/95/$9.50
SSDI
0899-7cv1(94)ooom2
JANUARY-MARCH
1995
CALCIFIC SOFT TISSUE
LEIOMYOMA
OF THE SHOULDER
5
FIGURE 1. Anteroposterior radiograph of the left shoulder shows prominent mulberry-like calcifications. No bony change is seen. large tumors, and calcium is usually laid down in district spherules reminiscent of psammoma bodies (1). Sometimes the calcification is characteristic of that seen in uterine leiomyomas (3-6). ln our patient, the most particular radiographic finding was these calcifications. These calcifications may lead to diagnoses such as tumoral calcinosis, myositis ossificans, chonclrosarcoma, chonclroma, synovial sarcoma, or calcifying neurilemmoma. Radiographs of tumoral calcinosis (Figure 4) reveal circular or oval
B
FIGURE 2. Axial CT scan of the left shoulder demonstrates a soft tissue tumor with conglomerate calcifications.
C FIGURE 3. MRI of the left shoulder. (A) Coronal ‘I% weighted image shows low-intensity tumor with signal void. (B) Axial ‘IPweighted image shows high-intensity tumor with signal voids. (Cl Coronal enhanced ‘IX-weighted image shows homogeneous enhancement of the tumor matrix.
6
DE MOW
CLINICAL IMAGING VOL. 19, NO. 1
ET AL.
Synovial sarcoma. Anteroposterior radiograph 6. of the left forearm shows scattered irregular calcification (arrows) within the soft tissue mass. FIGURE
FIGURE
4. Tumoral calcinosis. Antemposterior radiograph of the left foot shows extremely dense multiloculated calcifications around the fifth metatarsophalangeal joint.
well-demarcated masses of calcium about articulations. A lobulated inbomogeneous appearance is characteristic (7). In addition, tumoral calcinosis usually does not show a soft tissue component on CT or MRI (8), and can be differentiated using these modalities. Myositis ossificans (Figure 5) can be differentiated by recognizing the trabecular pattern within the dense
5. Myositis ossificans. Anteroposterior radiograph of the elbow shows shell-like calcification along the midshaft of the humerus (arrow). A radiolucent zone is noted between the calcification and the bony cortex.
FIGURE 7. Chondrosarcoma. Anteroposterior radiograph of the left shoulder shows stippled and irregular calcifications around the proximal humeral metaphysis (arrow).
FIGURE
JANUARY -MARCH
1995
CALCIFIC SOFT TISSUE
areas of calcifications and its conformity to the muscle plane (7,9). Synovial sarcomas (Figure 6) frequently calcify (10, 11); however, the calcifications are usually scattered and irregular, and cortical erosions are also noted. Although neurilemmomas can calcify due to degenerative changes, the calcifications are very rare (7). It would appear that chondrogenic tumors presented the greatest problem of differential diagnosis in our patient, since the pattern of calcifications resembled that of chondrogenic tumors (chondroma or welldifferentiated chondrosarcoma) (Figure 7), and the signals for tumor matrix on plain MRI also were similar to those for chondroid matrix. However,these chondrogenie tumors usually show rim or arc enhancement (12, 13) and could be differentiated using enhanced MRI. To our knowledge, this is the first report of a soft tissue leiomyoma with prominent calcifications arising during late childhood, that also provides MRI evaluation of the lesion. Although the MRI findings were not specific to leiomyoma, MRI was more helpful than CT in defining the tumor extent and analyzing the tumor pathology. REFERENCES I. Enzinger FM, Weiss SW (eds): Soft Tissue Tumors, 2nd ed. St. Louis: CV Mosby, 1988.
LEIOMYOMA
OF THE SHOULDER
7
2. Yanopoulos K, Stout AP. Smooth muscle tumors in children. Cancer 1962;15:958-971. 3. Ledesma-Medina J, Oh KS, Girdany BR. Calcification hood leiomyoma. Radiology 1980;135:339-341.
in child-
4. Ross LS, Ecstein MR, Hirschhorm R, Khapra AH, Shylman S, Hochstim RJ. Calcified leiomyoma: an unusual cause of large soft-tissue calcification of calf in childhood. NY State J Med 1983;83:747-749. 5. Lubbers PR, Chandra R, Markle BM, Downey EF. Case report 421:calcified leiomyoma of the soft tissue of the right buttock. Skeletal Radio1 1987;16:252-256. 6. Herrhin K, Willen H, Rydholm A. Deep-seated soft tissue leiomyomas: report of four patients. Skeletal Radio1 1996; 19:363-365. 7. Resnick D, Niwayama G (eds): Diagnosis of Bone and Joint Disease, 2nd ed. Philadelphia: WB Saunders, 1988. 8. Martinez S, Vogler JB III, Harrelson JM, Lyles KW. Imaging of tumoral calcinosis: new observations. Radiology 1990;174: 215-222. 9. Samuelson KM, Coleman SS. Non-traumatic myositis ossificans in healthy individuals. JAMA 1976;235:1132-1133. 10. Varela-Duran J, Enzinger FM. Calcifying synovial sarcoma. Cancer 1982;50:343-352. 11. Wright PH, Sim FH, Soule EH, Taylor WF. Synovial J Bone Joint Surg [Am] 1982;64:112-122.
sarcoma.
12. Aoki J, Sone S, Fujioka F, et al. MR of enchondroma and chondrosarcoma: ring and arcs of Gd-DTPA enhancement. J Comput Assist Tomogr 1989;15:1011-1016. 13. Geirnaerdt MJA, Bloem JL, Euldevink F, Hogendoorn PCW, Taminiau AHM. Cartilaginous tumors: correlation of gadolinium-enhanced MR imaging and histopathologic findings. Radiology 1993;186:813-817.