Dr. MUZNA NANAA Candidate

STUDY OF SOFT TISSUE LESIONS AROUND THE HIP IN ADULTS BY MRI

1024/1023

STUDY OF SOFT TISSUE LESIONS AROUND THE HIP IN ADULTS BY MRI

1024/1023

STUDY OF SOFT TISSUE LESIONS AROUND THE HIP IN ADULTS BY MRI

قذيج هذِ انزسانت اسخكًاالً نًخطهباث َُم شهادة انذراساث انعهُا فٍ اخخصاص األشعت انخشخُصُتيٍ كهُت انطب انبشزٌ بجايعت حهب 1024/1023

حصزَح

أصرح بأن هذا البحث بعنوان: دراست آفاث األَسجت انزخىة حىل يفصم انىرك عُذ انبانغٍُ بانًزَاٌ

نى َسبق أٌ قبم نهحصىل عهً أٌ شهادة والهى يقذو حانُاً نهحصىل عهً أٌ شهادة اخزي

43 :)1( جدول )2(: 44 45 46 :)4( 46 :)5( 47 :)6( 48 :)7( 49 :)8( 49 :)9( 50 :)11( 51 :)11( 51 :)12( 52 :)13( 53 :)14( 53 :)16( 54 :)16( 55 :)17( 58 :)18( 59 :)19( 60 :)21( 61 :)21( 61 :)22( 61 )23( 62 :)24( 65 :)25( 66 :)26( 67 :)27( 68 :)28( 68 :)29( 69 :)31( 70 :)31( 70 :)32( 70 :)33( 71 :)34( 71 :)35( 71 :)36( 72 :)37(

43 1

مخطط )2(: 44

45 :)3( 46 :)4( 47 :)5( 47 :)6( 48 :)7( 49 :)8( 50 :)9( 51 :)11( 52 )11( 52 :)12( 53 :)13( 54 :)14( 54 :)15( 55 :)16( 65 :)17( 66 :)18( 67 :)19( 68 :)21( 69 :)21( 69 :)22( 70 :)23( 71 :)24( 72 :)25( 72 :)26( SUMMARY :)1( )2( :)3( )4(: صور Coronal FS PD FSE. :)5( :)6( :)7( :)8(

:)9( :)11( “fascicular sign” :)11( :)12( :)13( :)14( Inflammatory pseudo tumor:)15(

Anatomy ]



 4

:)1(



:)2( 5

:)3( 6

 

 7



ASIS 8

X-RAY

. . Calcific Tendonitis Juxta-articular osteocartilagenous masses of Synovial Chondromatosis Mature Peripheral Calcification of Myositis Ossificans Nonspecific Dystrophic Calcification with in a mass of Synovial Sarcoma .

. Bone destruction, remodeling, scalloping,Periosteal reaction

. . .

Snapping Hip Syndrome  Tenosynovitis  Tendon Tear  CTSCAN 9

.Zonal Pattern Of Mineralization Bone scan

99mTC .

MRI

    

T1W 

T2W  )STIR( 

T1W 

T2*GRE  11

تصنيف آفات األنسجة الرخوة حول مفصل الورك [4-9]

Rotator cuff tear . Muscle Strain . Muscle Contusion . Avulsion Fractures . .

Inflammations

Bursitis . Myositis . Cellulitis . Abscess .

Tumor like lesions

MO . Hematoma . Morel Lavelle lesion .

Soft tissue Tumors 11

[5]) ( .

♂>♀

Tendinosis  Partial Tear  Full-Thickness complete tear 

MRI

  T1WI  T2WI  FS PD FSE   FS PD FSE and T2 FSE lmages 12



PD T1 Fatty atrophy  %25   13

[5-6] Muscle Strain .

MUSCLUOTENDINOUS JUNCTION( MTJ) %30

♀>♂

. .

STAGING, GRADING OR CLASSIFICATION CRITERIA : I %50 : II :III A : III B

MRI T1WI 

  14

:T2WI Strain Grade I 

. )-/+(  

Coronal FS PD FSE :)4(

:Strain Grade I I %50   

:Strain Grade I I I MTJ  .MTU  15

[5-6]Muscle Contusion .

♀>♂ :)5( FS PD FSE

MRI T1WI 

 T2WI 

)-/+(  16

[5-6] Avulsion Fractures .

ILIac Crest . :ASIS . AIIS . :Lesser and Greater Trochanter . Ischial Tuberosity .

MRI

T1WI  :STIR orT2WI   17

♂ > ♀

  MRI 18

[6]PIRIFORMIS SYNDROME

♂>♀

)sciatica( %6

Axial PD Image T2

:)7(

[6]BURSITIS .

Ileopsoas  Trochanteric  Ischiogluteal  ILEOPSOAS BURSITIS

%15

♂ ♀

)AVN( 21

MRI

:T1WI    :T2WI   tail-like  Tear-drop   :T1W C+  

A, Coronal STIR image B, Axial T1W image :)8(

    

.NSAIDS, 21

SNAPPING HIP SYNDROME [5]

40 15

♂>♀

Loose Bodies ,Para labral cyst

FS PD FS

FS PD FS 22

TROCHANTERIC BURSITIS[5]

. MRI T2WI

A, Coronal STIR image B, Axial image :)9(

MYOSITIS [8] .

%90

MRI T1WI

T2WI

. 24

CELLULITIS[8] .

MRI 25

[8] ABSCESS .

mottled appearance

MRI

Gradient Echo Imaging

99m TC MDP أو IN-labelled leukocyte scintigraphy 111 26

[5-6]TUMOR LIKE LESIONS

MYOSITIS OSSIFICANS .

)Centrifugal .)Zonal Phenomenon

8 6

♀>♂

.%)70 60( .Paraplegia

)radiolucent cleft( 6 4 الرنين تتنوع موجودات الرنين المغناطيسي حسة عمر اآلفة

:T1WI T2WI

-\+ 27

: T1+C

T2WI

: T1+C

: T1+C Magnetic Susceptibility :Gradient Echo Imaging

T2WI

:Parosteal Osteosarcoma MFH )dotted veil( : Rhabdomyosarcoma,Synovial Sarcoma

Calcific Tendonitis

MO Focal Myositis 28

HEMATOMA .

T1WI T2WI

.T1WI T2WI

 

:)10(

MOREL LAVALLEE LESION .

MRI

T2WI T1WI

. Sarcoma , Hemangioma , 31

[5-9]

[4-9] .

Lipoma  %50 75-5

MRI T2W T1W STIR 60- AGGRESSIVE FIBROMATOSIS ) DESMOID 

MRI T2W T2W T1W

BPNST 

5 SCHWANNOMA 50-20   NEUROFIBROMA 31

30-20   )PLEXIFORM NF)  MRI

:)11(

“fascicular sign” MYXOMA 

HEMANGIOMA 

MRI

flow voids 32

[4-9] .

MALIGNANT FIBROUS HISTIOCYTOMA 

Storiform :Pleomorphic Myxoid Inflammatory storiform,pleomorphic %16

90-10

♀>♂

.%50 .%25

MRI

T1W T2W

LIPOSARCOMA  .MFH

Well differentiated Myxoid Round- cell Pleomorphic 33

De-differentiated

.%19

60-40 MRI %75> T1W T1+C Synovial sarcoma 

40-20

♀=♂

MRI T1WI T2WI T2WI T1WI

:T1+C CT %30-25 T1WI

%25 %90 C 34

MPNST  -3 %70-25 MPNST %13

50-20

PDG-PET scanning GA-67 citrate .NF1 MRI , 5cm >

T1+C

LEIOMYOSARCOMA 

6-5 MRI 35

 

    

[10] STAGING

[7-8]

%35-5

.[11]

GRADE

تجعل 36

[11]FOLLOW-UP STRATEGY .

BASELINE MRI . 8-6

. MRI .

STIR T2WI 

. MUSCLE TEXTURE SIGN .

DIFFUSION .RESTRICTED DIFFUSION[9]  37



4-2 18-6 



NEOADJUVANT CHEMOTHERAPY



Figure(12): Algorithm for the MR approach to a patient with a suspected local recurrence of a soft tissue sarcoma SI, signal intensity[9].

Coronal T1-weighted axial T2-weighted fat suppressed fast spin echo images. :)13(

Axial T2-weighted fast spin echo, T1-weighted pre and post-intravenous gadolinium and dynamic sequence with regions of interest (ROI) and time/signal intensity curve. :)14(

Coronal STIR and dynamic sequence with regions of interest (ROI) and time/signal intensity curve. STIR Inflammatory pseudotumour :)15( 39



 □ □ □ □ □ □ □ □ □ □ □ □  □ □ □ □ □ □ □ □ □ □ □ □  □ □ □ □

 □ □ □ □ □ □ □ □ □ □ □ □ □ □ 42

:NT Philips -1  قوة 1 Max Gradient Amplitude ( 20 MT/m)  Integrated Body Coil:  Philips INTERA 1.5  Max Gradient Amplitude ( 33 MT/m)  Integrated Body Coil 

.) Cor: T1W/ T2W / STIR) 

.) Sag: T1W/ T2W) 

.(Axial: T1W/ T2W) 

TIW (Cor -AXIAL) 

T2*GRE  43

)60( 2012-2008

)%26.6( 4 10

)%73.3( 44

:)1(

%54.5 24 Inflammations (Myositis –myotendonitis- bursitis-cellulitis-abscess) %36.3 16 Tumors %9 4 Muscle strain

SOFT TISSUE LESIONS 60.00% 54.50% 50.00% 40.00% 36.30% 30.00% 20.00% 9% 10.00% 0.00% Inflammations Tumors Muscle strain

:)1(

%54.5 44

جذول )2(:

%43.1 19 %56.8 25

43.10%

56.80%

مخطط )2(: 45

)24(

)%50( 12  )%25( 6   2   2حالة خراجة مزمنة تحت الجلد.

%50 12 ILEOPSOAS BURSITIS %25 6 MYOSITIS %8.3 2 TENDONITIS %8.3 2 CELLULITIS %8.3 2 ABSCESS

%8 %8 %9 %50

%25

:)3( 46

%83.3 10 %16.7 2

90.00% 80.00% 70.00% 60.00% 50.00% 83.30% 40.00% 30.00% 20.00% 16.70% 10.00% 0.00%

:)4(

:)5( 47

0% 16.60%

83.30%

:)5( .%16.6 %100

:)6(

%100 12 %66.6 8 %100 12

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

:)6( 48

AVN  54   

 

:)7(

%25 2 2 %75 6 2 4

75.00%

25.00%

0.00% 10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%

:)7(

DVT

HAMSTRING %25 %75

:)8(

%75 3 %25 1

80.00% 70.00% 60.00% 50.00% 40.00% 75.00% 30.00% 20.00% 10.00% 25.00% 0.00%

:)8(

:)9(

%75 3 %25 1

:)10(

%25 4 MFH %25 4 LIPOMATOSIS %12.5 2 LIPOSARCOMA %12.5 2 SYNOVIAL SARCOMA %12.5 2 EXTRASKELETAL EWING SARCOMA %12.5 2 AGRESSIVE FIBROMATOSIS SOFT TISSUE TUMORS

AGGRESSIVE FIBROMATOSIS 25 12.5 12.5 EXTRASKELETAL EWING SARCOMA 12.5 SYNOVIAL SARCOMA 25 12.5 MFH

LIPOMATOSIS

:)9(

MFH 51

:)11(

%62.5 10 %37.5 6

TUMOR TYPE 70.00% 60.00% 50.00% 40.00% 30.00% 62.50%

20.00% 37.50% 10.00% 0.00% BENIGN MALIGNANT Category 1 Category 2

:)10(

:)12(

%40 4 %60 6

FEMALE 60%

MALE 40%

0% 10% 20% 30% 40% 50% 60% 70%

)11)

:)13(

%60 6 %40 4

70% 60% 60%

50% 40% 40%

30%

20%

10%

0% RIGHT LEFT

:)12(

)%37.5( 6 .LIPOSARCOMA , MFH , Agressive Fibromatosis 53

:)14(

%70 7 %60 6 %90 9 %90 9 %100 10

90% 100% 90% 100% 90% 90% 80% 70% 60% 60% 50% 40% 30% 20% 10% 0%

:)13(

:)15(

%10 1 Grade1 %30 3 Grade2 %60 6 Grade3 54

10%

Grade1 30% Grade2 60% Grade3

:)14(

:)16(

%40 4 %20 2 SEROMA %20 2

40% 40%

30% 20% 20% 20%

10%

:)15( 55

:)17(

%30 3 %20 2

20%

30%

0% 5% 10% 15% 20% 25% 30% 35% :)16(

:Accuracy

T.P+T.N 100 × Total

Specificity

T.N 100 × = % T.N + F.P

:T.N

F.P

:Sensitivity 57

T.P 100 × T.P + F.N

T.P

: F.N

:)P.P.V ( Positive predictive value

T.P 100 × = %P.P.V TP + FP

:T.P : F .P

:)N.P.V (Negative predictive value

T.N 100 × = % ( N.P.V) F.N + T.N

:T.N : F.N 58

:)18(

%93.1 %89.4 %96 %92.3 %94.4



.%100

%97.3 %100 

.% 97.7

%100 %66.6 

.%97.7 59

:)19(

%95.4 %100 %66.6 %100 %95 61

:)20(

%95.4 %92.8 %100 %88.8 %100

AGRESSIVE .FIBROMATOSIS

:)21(

%96.6 %95.4 %96.9 %90.9 %96.9

:)22(

%90.9 %97 %70 %87.5 %91.6

)23(

%86.3 %94.1 %60 %75 %88.8 62

:)24(

%95.4 %89.1 %90 %69.2 %97

66.6( %30

.]11[

الذراسات المقارنة 1. Imaging features of iliopsoas bursitis. .2002 WUNDERBALDINGER

2. Imaging of the hamstrings. 2008 Davis KW. 3. The proximal hamstring muscle-tendon-bone unit: a review of the normal anatomy, biomechanics, and pathophysiology. 2012 Beltran L

4. Thigh muscles injuries in professional soccer players: a one year longitudinal study. .2014 Corazza A

5. Magnetic resonance imaging of soft-tissue tumors of the extremities: A practical approach . 2013 Wing P Chan

6. Differentiating benign and malignant soft tissue masses by magnetic resonance imaging: role of tissue component analysis. 2009 ChenCK

7. Magnetic resonance imaging of soft tissue tumors. 1992 De Schepper AM

8. MR imaging of soft-tissue masses: diagnostic efficacy and value of distinguishing between benign and malignant lesions.

1995 Moulton JS 64

9. Value of MR findings in predicting the nature of the soft tissue lesions: benign, malignant or undetermined lesion? 1996 Soler R 10. Can MR Imaging Be Used to Predict Tumor Grade in Soft-Tissue Sarcoma? 2014 Zhao F

11. Post-operative imaging of soft tissue sarcomas. 2008 James SL

12. Fast magnetic resonance imaging with contrast for soft tissue sarcoma viability. .2002 Shapeero LG

:)25( WUNDERBALDINGER %100 %100 %66.6 %88 %100 %100

100% 100% 100% 100% 100% 88% 80% 66.60%

60%

40% WUNDERBALDINGER دراستنا 20% دراستنا 0% WUNDERBALDINGER

:)17( 66

:)26( Davis KW %100 %100 %98 %95.4

98% 95.40% دراسةDavis KW دراستنا 100% 100%

92% 94% 96% 98% 100%

:)18( 67

:)27( Corazza A HAMSTRING %48.1 %75

75% 80%

60% 48.10%

40%

20%

:)19( Corazza A

:)28( دراسةSoler R %60.7 %66.6 %77.7 %97.3

120.00%

97.30% 100.00%

77.70% 80.00% 66.60% 60.70% 60.00%

40.00%

20.00%

0.00%

:)20(

:)29( Moulton JS %55.8 %66.6 69

%55.80 دراسةMoulton JS

%66.60 دراستنا

50.00% 55.00% 60.00% 65.00% 70.00%

:)21(

Moulton JS

:)30( De schepper Chen.ck %98 %90.9 %97 %84.8 %87.5

98% 97% 98% 96% 94% 90.90% 92% دراستنا 87.50% 90% 88% دراسة Chen.ck 84.80% 86% دراسة De schepper 84% 82% 80% 78%

:)22( 71

:)31( De schepper %94 %94.1 <6.6سم %89.1 %87

96.00% 94.10% 94% 94.00%

92.00% 89.10% 90.00% 87% 88.00%

86.00%

84.00%

82.00%

:)23(

. De schepper

:)32( De schepper

%88 %90

:)33( Wing P Chan %95 %100 71

Wing P Chan

:)34( Soler R Moulton JS %96 %89 %96.9 يالحظ تقارب النتائج تين دراستنا ودراسةSoler R

:)35( Zhao F %16.8 %10 Grade1 %35.7 %30 Grade2 %47.3 %60 Grade3

100%

47.30% 80% 60% Grade 3 60% Grade 2 40% 35.70% Grade1 30% 20% 10% 16.80% 0%

:)24( Zhao F

:)36( James SL SEROMA %18 20% 72

18%

20%

17% 18% 18% 19% 19% 20% 20%

:)25(

:)37( James SL Shapeero LG %20 %21.4 %30

30% 30% 21.40% 20% 20%

10%

:)26( 73

%73.3 44 %26.6 16 30 )85-18

%54.5 24 

%50 . .

%36.3 16  . . MFH هو . %94.1 %97 . .%89.1 6.6> . %66.6 . .%20 %40 %90.9 %30 . .%20 %9 4  74

SUMMARY Soft tissue lesions around the hip are common in generally and particularly in athletes.MRI aids detection of soft tissue lesions and allows specific diagnosis. MR imaging is the modality of choice when clinical examination is suspected for soft tissue disease and plain radiographs are normal or equivocal. The role of MRI is retrospectively evaluated in the state of 60 Patients entered Aleppo Hospital or Al-Kindi Hospital through (2008-2012), they had clinical symptoms around the hip, ranging in age(18-85)years,44 of them had soft tissue lesion 73.3%, they underwent Our study included 44 patients with soft tissue lesions around the hip.

Results:  Inflammations are the most common soft tissue lesions around the hip joint in our study 54.5% followed by tumors 36.3% and strains 9%.  ILEOPSOAS BURSITIS is the most common inflammatory soft tissue lesion 50% in our study followed by MYOSITIS 25%.  Sensitivity, specificity and accuracy are 100% for diagnosis of Ileopsoas bursitis in our study.  Sensitivity of 100%, specificity of 98.1% and accuracy of 98.3% for diagnosis of myositis.  Sensitivity of 66.6%, specificity of 100% and accuracy of 98.3% for diagnosis of myotendonitis.  Malignant soft tissue tumors are more common than benign in our study.  The most specific sign of malignancy was tumor necrosis in our study 97% followed by neurovascular bundle involvement 94.1% followed by tumor size>6.6cm 89.1%.  MFH is the most common malignant soft tissue tumor and LIPOMATOSIS is the most common benign soft tissue tumor in our study.  Accurate diagnosis can be made by MRI only for 30% of malignant tumors and for 66.6% of benign tumors.  Dynamic gadolinium enhanced MRI imaging was done to follow up postoperative soft tissue sarcoma with accuracy of 90.9%. We were able to differentiate residual Tumor 40% from postoperative inflammatory changes 20%.  When monitoring post-operative sarcoma through 2 years, there were Tumor recurrence 30% and distant metastases 20%.

References 1) PAUL BUTLER: Applied Radiological Anatomy for Medical Students © Paul Butler, Adam W. M. Mitchell and Harold Ellis 2007

2) R. Kent Sanders: DI-Anatomy musculoskeletal First Edition Copyright B.j. Manaster MD, PhD, FACR 2006

5) Stoller, David W. Magnetic Resonance Imaging in Orthopaedics and Sports Medicine 3rd Edition Copyright ©2007 Lippincott Williams & Wilkins 6) A. M. Davies, K. Johnson, and R. W. Whitehouse: Imaging of the Hip & Bony Pelvis Copyright © 2006, Springer-Verlag Berlin 7) Nicholas C. Gourtsoyiannis ・ Pablo R. Ros : Radiologic-Pathologic Correlations from Head to Toe Copyright 2005, Springer-Verlag Berlin

9) DAVID SUTTON TEXTBOOK OF RADIOLOGY AND IMAGING. SEVENTH EDITION, London. 10) file:///C:/Users/VPC- CW2PFX/Desktop/%D8%A7%D9%84%D8%AF%D8%B1%D8%A7%D8%B3 %D9%87/cases/tumors/Magnetic%20resonance%20imaging%20of%20soft%20 tissue%20tum...%20%5BJ%20Belge%20Radiol.%201992%5D%20- %20PubMed%20-%20NCBI.htm 66

13) Chapman Stephen: Aids to Radiological Differential diagnosis fourth edition, British Library, UK, 2003

16) Dahnert, Wolfgang: Radiology Review Manual 6th Edition Copyright ©2007 Lippincott Williams & Wilkins 17) Robert R. Edelman, John Hesselink, and Michael Zlatkin Clinical Magnetic Resonance Imaging ; 3 edition (October 21, 2005)

18) file:///C:/Users/VPC CW2PFX/Desktop/%D8%A7%D9%84%D8%AF%D8%B1%D8%A7%D8%B3 %D9%87/cases/tumors/Fast%20magnetic%20resonance%20imaging%20with% 20c...%20%5BClin%20Orthop%20Relat%20Res.%202002%5D%20- %20PubMed%20-%20NCBI.htm

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Declaration

It is hereby I declare that this work:

STUDY OF SOFT TISSUE LESIONS AROUND THE HIP IN ADULTS BY MRI

Has not already been accepted for any degree nor it is being submitted at present for any other degree.

Dr. MUZNA NANAA Candidate

CERTIFICATION

It is hereby certified that the work described in this thesis is the result of the candidate's own investigation under the supervision of Dr. ALAA KAYALY Doctor at the Department of radiology, faculty of Medicine, Aleppo University. And any reference to other researcher's work has been dully acknowledged in the text. Dr. ALAA KAYALY Dr. MUZNA NANAA Supervisor candidate

Aleppo University Faculty of Medicine Department of Radiology

STUDY OF SOFT TISSUE LESIONS AROUND THE HIP IN ADULTS BY MRI

Thesis for Master Degree in Diagnostic Radiology

Submitted by: Dr. MUZNA NANAA

Supervised by: Dr. ALAA KAYALY

Submitted in partial fulfillment of requirements for master degree in diagnostic radiology at the Faculty of Medicine , Aleppo University. 2013/ 2014

Aleppo University Faculty of Medicine Department of Radiology

STUDY OF SOFT TISSUE LESIONS AROUND THE HIP IN ADULTS BY MRI

Thesis for Master Degree in Diagnostic Radiology

Submitted by: Dr. MUZNA NANAA

Supervised by: Dr. ALAA KAYALY

2013/ 2014

Aleppo University Faculty of Medicine Department of Radiology

STUDY OF SOFT TISSUE LESIONS AROUND THE HIP IN ADULTS BY MRI

Thesis for Master Degree in Diagnostic Radiology

Submitted by: Dr. MUZNA NANAA

2013/ 2014