Soft Tissue Masses in Children

SOFT TISSUE MASSES IN CHILDREN

Imaging lessons learned (some the hard way)

Kathleen H. Emery, MD

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@CincyKidsRad facebook.com/CincyKidsRad

World Health Organization - Soft Tissue Tumor Classification 2013

• Adipocytic Tumors • Fibroblastic / Myofibroblastic Tumors • So-called Fibrohistiocytic Tumors • Smooth-muscle Tumors • Skeletal-muscle Tumors • Vascular Tumors • Nerve Sheath Tumors RadioGraphics 2007;27:509-523 • Tumors Of Uncertain Differentiation (includes synovial cell sarcoma) • Undifferentiated / Unclassified Sarcomas (many of these called MFH in the past) http://sarcomahelp.org/reviews/who-classification-sarcomas.html Soft tissue masses/tumors - Overview • Imaging approach • General principles • Age related differential diagnosis • 5 lessons learned Soft tissue masses/tumors • Imaging approach • General principles • Age related differential diagnosis • 5 lessons learned Palpable mass

X-ray US

Calcification- Diagnostic Indeterminate ?myositis STOP ossificans MRI

CT Determinate Indeterminate

Biopsy

Modified from Ahlawat & Fayad. Pediatrics July 2015,136(1):e194-e202 17Y girl with “foot bump”

T2 FS T1 FS +C Soft tissue masses/tumors • Imaging approach • General principles • Age related differential diagnosis • 5 lessons learned General principles • Majority of ST masses are benign • Vascular anomalies are most common – heterogeneous group • Age, location, clinical history – important • Identification of adipose tissue – helpful • Doppler – don’t just rely on color flow Soft tissue masses/tumors • Imaging approach • General principles • Age related differential diagnosis • 5 lessons learned Patient < 2 yrs • Vascular lesions – tumors/malformations • Fatty “tumors” (lipoblastoma, involuting infantile hemangioma, fibrous hamartoma of infancy) • Infantile myofibroma/myofibromatosis • Infantile fibrosarcoma • Inflammatory (abscesses, subcutaneous granuloma annulare, etc.) Older Child

• Traumatic (hematoma, myositis ossificans, etc.) • Vascular lesions • Myxoid liposarcoma • Rhabdomyosarcoma (any age) • Other sarcomas Vascular Anomalies

Vascular Vascular Tumors Malformations

Hemangioma Hemangioendothelioma Angiosarcoma Venous

Infantile Congenital Kaposiform Others Lymphatic

RICH Spindle Cell Tufted angioma Arterial NICH Pyogenic Epithelioid granuloma Capillary PHOST Others

FAVA Combined

1: Mulliken JB, Glowacki J. Plast Reconstr Surg. 1982 Mar;69(3):412-22. PubMed PMID: 7063565. 2: Mulliken JB, Glowacki J. Plast Reconstr Surg. 1982 Jul;70(1):120-1. PubMed PMID: 7089103. 8d infant f/u age 5 mo 2d infant, leg mass

http://www.pediatricsconsultantlive.com

T1 FS +C

T2 T1 fs post T2 FS T1 FS +C Soft tissue masses/tumors • Imaging approach • General principles • Age related differential diagnosis • 5 lessons learned 2Y girl – buttock T1 T2 FS asymmetry Lipoblastoma

7m boy – Fibrous elbow mass hamartoma of infancy Sag T1 Cor STIR T1 FS +C

12Y Well diff. boy liposarcoma

Lipoma 19Y girl 5 lessons learned • Fat is generally a good thing (pt age is most predictive of type of lesion)

High Scalability T2 FS T1 FS +C Cystic met (adamantinoma)

Cat scratch 5 lessons learned • Fat is generally a good thing (pt age is most predictive of type of lesion) • Not everything that is “cystic” is a cyst High Scalability 5Y boy R shoulder mass T2 FS T1 FS +C

Soft tissue Ewings sarcoma AJR 2014; 202:1281–1290 (Fig 14) T1 +C T2 FS 17 y boy medial ankle pain 11 y girl, CP, erythema, edema

T2 FS

T1 FS +gad 5 lessons learned • Fat is generally a good thing (pt age is most predictive of type of lesion) • Not everything that is “cystic” is a cyst • “Cyst” on MR not clearly connected to High Scalability joint – give gad 5 mos later T2 FS

T1 FS +C

STIR T2 No FS 5 lessons learned • Fat is generally a good thing (pt age is most predictive of type of lesion) • Not everything that is “cystic” is a cyst • “Cyst” on MR not clearly connected to joint – High Scalability give gad • Intra-articular mass-like “fluid signal” – give gad 10Y girl Thigh lump 13Y boy 5 lessons learned • Fat is generally a good thing (pt age is most predictive of type of lesion) • Not everything that is “cystic” is a cyst • “Cyst” on MR not clearly connected to joint – High Scalability give gad • Intra-articular mass-like “fluid signal” – give gad • Imaging ≠ histology ≠ schoolsupplies.searchub.com 3.5Y boy, arm mass, poss NAT 17Y boy, L groin mass, no trauma T2 FS GRE T2 FS GRE

T1 FS

Pre-C Post-C T1 FS +C High grade sarcoma with Myositis ossificans epithelioid features (unchanged x-ray f/u) (abundant hemosiderin) Soft tissue masses/tumors - Overview • Imaging approach • General principles • Age related differential diagnosis • 5 lessons learned