Introduction | MRI of the Soft Tissue Mass
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Okay, so, what I'm going to talk about is a soft tissue mass? basically very often we end up being sent patients with soft tissue masses and we don't really know how to go about working them up effectively this is very common problem by look across the audience probably quite a few could point at something you some soft tissue don't really know what it is and some of you probably more neurotic about it than others but ...get a sent a lot of patience for evaluation of soft tissue bumps patients are always worried that

...going to be something really serious usually it's not but you have to have some sort of systematic way to go about it in order to kind of sort out what's going on and try to show you a little bit about how we approach it and some examples of what different things can be.

So, patients often present with these lamps and bumps and often you just reflects a very normal underlying tissues.

But, we don't know that for sure and sometimes you have to go for...further imaging. There's no real mystery about how you can how you go about doing as I'm hope you'll find out by the end of this There's a lot of different imaging modalities that we have available to us in order to evaluate soft tissue lumps ...bumps. Unlike when we looked at bone tumors yesterday radio graffiti really doesn't play a very big role so you're really can resort a lot more cross-sectional imaging

techniques exactly what you use is going to depend on what your experiences is and what you have available in your own institution so again there's several things

are going to try to achieve? First you want-to confirm there's actually something there sometimes people are worried about a soft tissue lumber bump and once you actually do imaging is actually nothing there to worry about if you do find something you like to characterize it get some sort of idea of exactly what it is

then if you find something and look serious...may have to stage the patient prior to therapy you do a biopsy and then once you've actually treated you have to follow it up I'm not going to try to cover all of that today so we're going to talk about detection and characterizations were going to concentrate on with this particular. Particular talk. So, often these things are quite vague

and since nothing maybe very understandable that's the case has to be more frequent impatiens that or obese very anxious individuals quite easy to sort of make-up a lumbar bump if you're anxious. ...may represent a very hard to detect lesion...things like a soft tissue like home they're very software often are very ... it soft borders or it's hard to really be sure ...something...very active people you may have muscle tears again very deep-seated can be very poorly margin needed to be a site of ...for instance or herniated through a piece of fashion I'll try to show you examples of all these things and some people series simply have variant anatomy may have an accessory muscle on one side and not the other and at some point they notice that this is an example of a light...this is in this up

detainees fat and if you look very carefully you can see that there's this.

This lesion but it's the same signal intensity on this mr scan as a surrounding fat so it's very hard to detect when you do a fat suppression sequence ...disappears so these things can be very hard to actually demonstrate sometimes the easiest way to demonstrate something like a subroutine is like palmer's actually ultrasound you see the margins between normal fat and abnormal fat far more vividly than you might on ct...ultrasound so things like this

are usually not serious and it's reassuring for a patient to know that it's just a simple like palmer that they don't have to worry about so when we try to characterize a lesion

several things you want to do you want to see if we can determine what's actually made out of show you an example of fat sometimes they contain calcium occasion humor citron which is old degraded blood products and depending on what we see is in it you can get an idea of what's actually made out of...or not it's worth worrying about it shape and

structure can also sometimes give us important clues as to what it is and finally its location will sometimes give us the important clues as well as I'll show you in a moment so here's an mr chrome lamar. And, is also a extended field of view ultrasound on the mars quite easy to see this rounded lesion it's got sort of these target like ...inside it when you look at the ultrasound you can see the lesion quite clearly tails coming out of either... Based on these characteristics this so-called target sign and the fact that you've got tails coming out of it, you know, it's going to be a nerve she's tumor energetic tumor this case is going to be astronomer you can be about ninety nine-point nine percent sure based on those characteristics just the signal characteristics that shape and location you don't really need a biopsy at all and if you do

the patient won't really enjoyed very much because it's a nerve right.

Another lesion a patient complain that the felt a lump underneath the tip of the scatter shoulder blade if you look carefully here you can see is this sort of stride...lesion on one side and not so much on the other ok this is an older patient, patient about the seventy-years-old. From this characteristic appearance this...sort of lesion with little bands in it and

...location under the tip of this gap this is what's called ...last two fiber almost going see them fairly often in older people this is a characteristic location you don't need to do anything else so just from its character its location, you know, exactly what it is okay so you've solve the mystery for that one.

The other thing we see quite frequently...patients to complain of sort of

...burning and riddick pain in their...especially if you get ...the foot from side-to-side if you look here...the same are you can see these little q drop things coming out...between them editorials... What's called a aroma of these things can be very symptomatic but they're not dangerous and from this appearance from its location in this area

...characteristic shape again you've got ...hundred-percent diagnosis essentially. ...thing we can see here on this...the anterior to that tell others ...lobby related cystic looking lesion with all these little membranes sitting in it ok. This is an irritated versus what...teller burst.

So, you know, the sometimes is called the house maids...for people that are on their knees all ...time or carpet layers knee...what this is basically is a chronically irritated...and I can present as a large alarming appearing mass. But, again, you can be pretty sure that you've got the correct diagnosis just from its location and ...characteristics.

...a little weird or this patient came complaining that there was this egg shaped lesion in

there but there was getting larger over time and if you look at look at this thing carefully can see ...rings a very low signal material like one-ring after another so what this indicates is that there's been a hammered here. What you don't always what's underlying this hemorrhage ...this thing hemorrhaging and this patient had been an attic wagons and people like that are more prone to developing hemorrhage for whatever reason even minor trauma so this

ended up being removed simply because he was driving the patient crazy? And, there was nothing found underneath it sometimes you get recurrent hammered you can be because ...small tumor underlying it that's bleeding it wasn't the case of in this in this instance but the fact we could see all these rings of ...sitter knew we knew that there was a large amount of blood product in this and indeed there was it was all just blood clot.

Sometimes you can see very low signal intensity material could see around this but teller tendon ...sequences quite low intensity particularly and what we call a gradient echo sequence? And, gradient echo sequences they're very sensitive to the presence of ...citron old degraded blood product and this thing is quite modulated okay looks fairly uniform...appearance.

So, any radiologist would look at this would think that based on the signal characteristics this is going to be something we call segmented villain ocular sinusitis so it's an abnormal sort of relatively non aggressive tumor...not going to task the size or kill the patient but can recur locally and again based just on the same are appearance your certainty

ofwhat this represents is very high sometimes the shape will help us this is a

...are the...up in this particular case you can see it there's this large lobby related mass? Okay, so, what this looks like you're a bunch of clump together lymph nodes...know there's a lot of lymph nodes in the x ...and a lot of tumors will actually go to lymph nodes

...can see in this particular case there's some areas of high signal within these lymph nodes that probably means has been a little bit of fresh bleeding that's occurred in it so what this represented is this patient...a tiny melanoma on their hand? And, this melanoma it spread the lymph nodes as is unfortunately the case that often happens quite often? And, you can suspect that that's the case of the fact that the temporarily because melanoma

does that you can't be sure exactly why the lymph nodes are large but from that shape you can probably suspect that these are abnormal lymph nodes. And, then sometimes some tumors what they'll do is they'll make a lot of college and essentially it's like scar tissue it tumor it's made up of virtually nothing but scar tissue we call ...moines some people are prone to developing these for genetic reasons we can see around the hip there's this thing is extremely

low signal intensity on all sequences and if you try to biopsy something like this is like trying to biopsy of baseball or as hard as a rock. But, you can tell just from the imaging characteristics in this particular case which you probably got something with a lot of college and. You can learn quite a bit from the signal characteristics

...this particular instance we can see on the mr.

There's this vague area of increase signal on tone okay so it probably has a bit of fat in it but it also looks kind of roping. On we look at the ttwo. Just like it was full of blood vessels we look at the gradient echo again we can see that low signal material we talked about earlier so it tells you there's probably some old blood ...there's all blood and it looks kind of rope

he may have a bit of fat in it so what this is a vascular ...formation you can be pretty much a hundred-percent sure based on the signal characteristics and the shape even if you didn't biopsy this sure. The other thing you can do of course as you do a color doppler show flow in it and then you're even more certain about it and...demonstrated the diagnosis very elegantly. So,...out what that soft tissue lump is.

...alluded to the fact that the...occasion if you see it in a soft tissue mass can sometimes give you some important tip offs as to what the nature of the lesion is as we discussed yesterday we looked at bone tumors classification can be due to the presence of bone within a lesion so-called asteroid. ...can be due to the presence of cartilage okay so we tend to get this sort of snowflake or flock

...tells application and sometimes it's just a stroke...vacation kelsey occasion it's as laid down disorganized fashion and each of these types of ...creation has different causes...just listed a few ...has examples but...certainly not an exhaustive list by any means. And, the classification sometimes we'll picked up for the first-time...a radio graph... is one instance where sometimes a soft tissue mass the characterize a shun actually begins with the radio graph

that sometimes is obtained in the emergency room or some other place. And, you can see callous vacations they can sometimes give you tip offs that, you know, maybe you're dealing with one of those venus or vascular mouth formations like I showed you a moment ago and the mr sometimes you can get abnormal bone... foreman soft issues especially if it's been traumatized some as you get a blood clot form...the bone and then it'll organize or rather in this like...

will form the soft tissues...organize over time into bone. And, sometimes if you really traumatized soft tissues it'll just die and ...produce something called cal civic my own across is another's kelso fide dead muscle.

So, this is an example of a for cans you could see that very clearly on the radio graph we have all this abnormal new bone that's

forming around the proximate to be in this case after the previous severe traumawhen you look at the ct you can see is truly has organized into a new ball right? Now of findings in this radio graph or a little more subtle but I think you can see in approximate cafeteria these little tiny areas of kelsey ...patient

...complaining they felt a lump there when we did the mr those little tiny areas of kelso vacation actually represented classification in a tumor in this very aggressive vicious sort of a tumor in spite of the fact that sort of looks ...fairly innocent here but the initial tip off was that ...that we saw on the radio graph when...patient went to the emergency room complaining of increasing pain.

These classifications look more rounded...some of them if you look at them they almost like look like calcium many calcium donuts right. ...what they call sleeveless these are calculations within a veins so this particular patient had a venus now formation and just based on the radio graph we can make that call you can say yeah, I know what the soft tissue masses so it's a...formation of vascular mel formation.

Now some masses will contain ...I showed you one initially when we started talking about characterization...sub palm. These various types of fat containing masses some most of them are very benign like commas or a dime-a-dozen you see hundreds of these things over the course that year and our my own practice but some

fat containing tumors are not so innocent so-called liposuction moments. And, these can sometimes be killers the former mayor of toronto rob for died of like what's our comb about a year-ago now or something like that. So, I'll show you a few examples of some of the things that contain fat we see in the soft tissues so we can see in this particular case that in the proximate cafes

...fat containing lesion notice the signals the same as the surrounding normal sub containers

fat and when we do a fat saturated sequence can see that fat disappears the same ways it does this up detainees fat? So, what they call inter muscular light comedies are pretty common these are not dangerous but sometimes people will notice notice a mass can sometimes grow very slowly? That's if they get to bigger they get uncomfortable sometimes they'll remove them but

certainly not anything to worry about as an example of a very benign very common fat containing lesion.

Sometimes people have chronic irritation in the from something like osteoarthritis especially in older or younger person that develops osteoarthritis say after an injury. Sometimes...up happening is that the fact that underlie agents...lining of the joint this

...vm becomes high perjure...starts enlarging that's when you get this sort of funny-looking appearance in the near on this ...get these sort of sausage like projections of fat going into the joint so-called like home arbor essence just based ...the shape of the franz of fat ...its location underneath the snow veal membrane again we can make

a very specific diagnosis without having to resort to anything more invasive.

And, sometimes of course fat it's dramatized ...talking about having him at home is showing up in a muscle for instance but you can also ...fat and that's when you get something called fact process. And, the fat also reacts to the this new process. That the dead fat is surrounded by the living fat living fat truck tries to

wall it off so often you'll get the sort of appearances were the area inside here still contains fat there's dead it's been walled off by the surrounding living fat and you see this quite often especially overs for instance hips or, you know, anything that will be ...easily traumatized.

Now this lesion if you look carefully you can see that there's areas and at that are high signal like the surrounding sub detainees fat other

areas of low signal compared to use simultaneous fat. when you do look at fats oppression you get this incomplete suppression of the fact? This is a bad. When you have lycos are commas sometimes they'll have areas of normal mature looking fat and the areas the worry the most about in a fat containing lesion or the areas that have less

...because those are likely to be the more dangerous the higher grade lesions malignant portion of a fat containing a circle so when you're planning a biopsy of something like this you always try to biopsy that part of the lesion that does not contain the fact that's likely to give you the most accurate answers to how aggressive the lesions going to be can also see this on ct this particular case you can see

there's this large fat containing lesion within the product...can see this is nodule and it doesn't contain anywhere near as much fat that's the nasty part of the lesion so when it comes to a biopsy that's the part you want to sampled since that's going to give you an idea of how aggressive it is and your therapy is going to be based around the most aggressive portion of that tumor so right away just looking at a lesion like that I can say right away that I know that this isgoing

to be liposuction moment it's the it's just like the sub type you can't tell but, you know, what's going to be a lycos are coma?

Another example of a fat containing lesion this one can see has calcium minutes rain anterior to the elbow you get the impression that there's areas of diminished attenuation around the ...bit of a strange-looking thing.

When you look at the mri though you can see that this lesion contains fat as well as calcium you can see the calcium into these low signal intensity areas okay and what this actually represents is a venus now formation venus now formations and soft tissues will often contain calcium not invariably okay they obviously have to have blood vessels in them ...almost always have at least a little fat if you see all three of those things together

you've got a slam-dunk diagnosis?

...the other thing that I mentioned is, you know, I mentioned all these different...tumors when...when I city or new classrooms rather in other words abnormal so the soft tissues that appear in the in these ...soft tissue lumps and bumps but sometimes very normal structures can sometimes mimic something that may be

...more sinister so I mention things like muscle herniated... okay something that we see...younger people muscle tears. Some people have accessory muscles is particularly common around ...places like the ankles we'll have an extra small muscle and one-sided not the other especially active people but also sometimes older people that are antique wagons will present with a growing mass and it turns out to just be a human tomorrow

believed and sometimes we get tend to notice or if you know, where you actually have fluid accumulating ...from something like overuse it can also...a mass? This is actually one fellow physician at the vancouver general came to me he was actually anesthesia all just a professor of anesthesia and he said, you know, I've got this big lump that appeared on my back in the last two weeks it's driving me crazy took

his shirt off and sure enough...have this huge lump on his back. And, he says I can get an mri so we did an mr. What he had was this area of increase signal? The posterior aspect of this lateral back. But, not very well-defined ...feathery looking what this is...a torn muscle...

look christmas door side muscle which he tore while he was water-skiing on holiday two weeks before okay so sometimes, you know, the context of something we'll give you clues as to what's likely to be this was a mimic of a... Now these are cross-sectional imaging...chest ok this came to us between christmas and new years. If you look carefully I don't think I need to persuade you that this guy has very large muscles I mean

is just huge bulky guy guys a body builder...complained that he had this massive appeared in his chest wrong it was quite painful and you can see here this is large him at Can see his picture alias major muscle ok is torn right in the middle of it this is a guy who was using anabolic steroids and his brother at bottom weight-lifting set he decided to try it out on christmas morning ...stacked up a whole bunch of weight he felt pain in his...what he done

...torn inspector alias muscle and this large mass appeared those two groups of people at the develop...less major tears your body builders that are on steroids and they're you know, elderly patients that usually have something like rheumatoid arthritis so the two groups this guy film the first group?


that sometimes you can characteristically see not so much in this part of the world if you look carefully on ...tip fib image you can see these small sort of rice like callous vacations and the soft tissues. Which is a parasitic infestation this patient Like either I wasn't sure what this was when I looked at it but we had a fellow that came from the middle east and he knew right away what it was.

again, not a great thing to's not...not going to kill you what about this thing. Well, this patient when you look the complain that he had a masses ...slowly growing for a few years come into the to the hospital he wanted evaluated I don't think I need to persuade you that this patient clearly has had previous drama ...this tip fit you can see all healed...but of course the thing it's a catches the biggest interest as large...bubble.

Like kelso five mass. Okay, this is something we call cal civic my it occurs in a patient typically in the lower extremity where they fracture lamb. The muscles in the anterior compartments of the leg. Okay, end up being traumatized as well.

And, because they're encased in fashion the pressure rises inside the muscles and normally what a surgeon will do is we'll go in and they'll do what they call a fashion release they'll just cut the fashion to relieve the pressure if you don't all a muscle inside that compartment dies. And, then it counts defies over time. And, it looks like this so it looks like a really nasty weird you know,

tumor patients get very worried about another example of it you can see in this particular case the...creation is all sheet like and this is again a very specific diagnosis that you can make just on the basis of sometimes a plane film you don't need to do anything else it doesn't matter-of-fact the last thing you want to do is interfere with it because it's all the tissue and there's dead if you

even do a biopsy it they tend to get infected and then and then it's a real mess. That's what it looks like on ct. Is heavy kelso vacation? This is something else that presented to...a few years ago... younger patient is about twenty-years-old complained that he had this mass appearing in his... and gotten larger over the space of a few weeks was extremely painful.

And, by the ...image them about a week-and-a-half later...kind of gone down in size. When you look at the anterior aspect of the earth I can see this area of abnormal muscle gadolinium in this case ...sort of has this kernel aided border? Turns out that this patient had been a diabetic since age for

...been insulin dependent diabetics for something like sixteen years. And, what this represents is a diabetic muscle and fart so these ...diabetes as, you know, tend to get accelerated vascular disease especially small vessels so what he done...actually infer acted his anterior thigh muscles the surgeon didn't believe me the so I biopsy

...and it came back is dead muscle? Patient came back about two months later the same thing happened on the other side so this is a well describedphenomenon so in conjunction with the history you can sometimes figure out what's going on in the soft tissues another athletic patient complain that very often

you had a mass at the end and hero lateral aspect of his thigh and this particular case you can use this muscle bulging out you can see where the muscle is

actually pushed its way out through a small terror in the fashion and sometimes you can best demonstrate this actually under ultrasound by getting a patient contracted muscle and you can actually see the muscle popping in and out of a fashion terror so again this isn't anything serious but it explains the patients clinical findings so they find that quite reassuring. And, sometimes patients just are made a ...lee you can see in this particular patient that

...up detainees fat in the right thigh is much bigger than the submitting is fat and the left so this isn't anything dangerous obviously but sometimes a statically it's not pleasing people notices and define...reassuring to get a proper explanation so I've tried to give you sort of an overview of how we approach

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