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IMAGING OF TUMOURS

Christian Dumontier, MD, PhD


Centre de la Main, Guadeloupe, FWI

With the help of Henri Guérini, MD,


DO WE NEED IMAGING ? - NO
• May be unnecessary

• Most hand tumors are benign

• Soft-tissue tumors: 70%


(ganglion 70%)

• Skin tumours : 25-30 %

• Bone tumours : 1-5%

• Clinical diagnosis is rather easy


in most cases
DO WE NEED IMAGING ? - YES

• Tumors that are symptomatic


need to be diagnosed and
staged.

• Clinical and family history,


physical characteristics of the
tumor, provide the basis of a
clinical impression

• Imaging studies are helpful to


improve the accuracy of our
diagnosis +++
DIAGNOSTIC STRATEGY

• 1st step: rule out a pseudotumour

• 23% of 134 masses were not tumors

Capelastegui A, Astigarraga E, Fernandez-Canton G, Saralegui I, Larena JA, Merino A. Masses and pseudomasses of the hand and
wrist: MR finfings in 134 cases. Skeletal Radiol 1999;28:498—507.
PSEUDO-TUMOUR

• Carpal boss

• Accessory muscles

• Granuloma

• Calcifications
HOW TO RULE OUT A PSEUDO-TUMOUR ?

Gout

• Orthogonal plain X-rays:

• Arthropathy ? Calcinosis

• Calcifications ?

• …

DIP Arthrosis
X-RAYS ARE ALWAYS NECESSARY !

?
HOW TO RULE OUT A PSEUDO-TUMOUR ?

• Sonography
Foreign body
• Easy access

• Not expensive

• Can be tip of the screw


performed by Wrist synovitis
the surgeon
Tz
Tz

Sc
Sc
DIAGNOSTIC STRATEGY
• 2 nd step: rule out a cyst : 40-60% of all hand
tumours

• Localisation

• Palpation

• Transillumination

• (Sonography)
GANGLION AND SONOGRAPHY

• Where does the stalk


come from ?

Dorsal scapholunate ganglion arising from the DRUJ

Dorsal ganglion in front of the DRUJ but


sonography showed us that the stalk came
from the scapholunate interval as usual
GANGLION AND IMAGING TECHNIQUES

• MRI is also efficient

• But sonography is cheaper,


easy to access and as
precise as MRI (in good
hands) as 95% of ganglia
have a typical sonographic
appearance

Teefey SA et al. Ganglia of the hand and wrist: a sonographic analysis. AJR Am J Roentgenol 2008;191: 716-720.
DIAGNOSTIC STRATEGY

• This is a tumor

• This is not a cyst

• 3rd step: characterize a tumor mass


WHICH TUMOR COULD IT BE ?
Ganglia 1024

Mucous cyst 192

Giant cell T. 173


• Almost 200 types of tumor
are classified by the WHO Glomus T. 79

Chondromas 73
• Most are rare or very rare
Schwanomas 44
• Non-cystic tumors Epidermal cysts 41
represented 25% of 134
masses, including 0,2% of Fibromas 23
malignant tumors 1714 tumours operated on
at the Institut de la Main
Capelastegui A, Astigarraga E, Fernandez-Canton G, Saralegui I, Larena JA, Merino A. Masses and pseudomasses of the hand and
wrist: MR finfings in 134 cases. Skeletal Radiol 1999;28:498—507.
CHARACTERIZE A TUMOR MASS

Plain X-rays
Bone or Soft-tissue
calcified tumour tumour
PLAIN X-RAYS

• Bone tumor are rare (5%


of hand tumors)

• Chondromas are the Chondroma


most frequent

• Analyse first localisation


(epiphysis, metaphysis,
diaphysis) and age

Giant cell tumour


• Age

• Tumor characteristics

• Type of bone resorbtion

• The tumor matrix

• Expansion or cortical rupture

• Periosteal reaction

• Adjacents soft-tissues

• Size and shape of the lesion

• Presence of septae, trabeculations,…

• Growth plate

http://www.radiologyassistant.nl/en
Age Well-defined Ill-defined Sclerotic

EG EG-Ewing osteosarcoma,
0-10 SBC leukemia
Osteosarcoma

NOF, osteoblast, Fibrous Osteosarcoma, Fibrous


10-20 dysplasia, EG, SBC, ABC, Ewing, EG, Osteosarcoma dysplasia, EG, Osteoid
Chondroblastoma, CMF osteoma, Osteoblastoma

Chondroma, osteoma,
Giant CT, chondroma,
bone island, parental
Chondrosarcoma, HPT-
20-40 Brown tumor,
Giant CT osteosarcoma, healed
lesions (NOF, EG, SBC,
Osteoblastoma
ABC,Chondroblastoma)

Metastases, myeloma,
Metastases, Myeloma,
40+ geode
chondrosarcoma (high Metastase, bone island
grade)

All ages infection infection infection


SECOND LINE INVESTIGATION ?

• CT scan

• Its excellent spatial


resolution provides an
excellent cortical analysis
and tumor matrix
assessment

Chondrosarcoma
3RD LINE: MRI
• MRI shows components such as cartilage, vascular
tissue, fat, liquid and haemosiderin

• MRI is superior in detecting bone marrow lesions -


Most bone tumours will be evident as lesions with
low signal against a background of surrounding
fatty marrow

• MRI assesses the degree of intramedullary


extension (and dimensions) and invasion of the
adjacent structures

• Most bone tumours and tumour-like lesions have a


significant amount of cartilaginous tissue
(hyperintense on T2WI).

• Gadolinium-based contrast medium helps


distinguish oedema from viable tumour and allows
an accurate determination of the degree of
vascularisation.

Chondroma
Chondroma
SOFT-TISSUE TUMORS
• Ultrasonography +++

• Excellent spatial and temporal


resolution,

• Can easily differentiate between


liquids, calcifications, fat, foreign
bodies, muscles and vessels and also
bone !

• Color Doppler ultrasonography is


useful to assess vascularity of a mass

• May guide infiltration or biopsy


procedures
Osteochondromatosis
hamartofibrolipoma of ulnar nerve
venous hemangioma
Glomus tumour nail bed
SECOND LINE INVESTIGATION: MRI
• Analyze the tumor matrix by
identifying fatty, cartilaginous and
cystic tissue

• Shows features of aggressiveness, sign


of malignancy: poorly defined margins,
invasion into vascular-nervous or
osseous structures, peritumoral
edema, heterogeneous signal in case
of necrosis and intense enhancement

• MR imaging helps discriminate


between benign and malignant lesions
with a sensitivity of 93% and a
specificity of 82%
Synovial sarcoma: Hypointense T1, hyper-intense on
fat suppressed proton density, Enhancement after
gadolinium injection
PERIPHERAL NERVE SHEATH TUMORS

• Can be seen with


sonography

• Better analysed with MRI

Median nerve schwanoma


PERIPHERAL NERVE SHEATH TUMORS
• T1 hypointense and T2 hyperintense

• Well-circumscribed, spindle-shaped mass

• Schwannoma is typically located


eccentrically with respect to the affected
nerve,

• Neurofibroma is centrally located within


the nerve and intimately associated with
the fascicles

• May demonstrate a “split fat sign” at the


periphery of the tumor as the fat splits
around the entering or exiting fascicles.

• A “target sign” with peripheral T2w-


hyperintense rim surrounding a central
area of low T2 signal intensity has been
described in neurofibromas
BONE SCAN
Bony metastases

• To demonstrate
unsuspected lesions
Osteoid Osteoma
• Screening in malignant
tumors (PET scan more
sensitive and specific)
VASCULAR INVESTIGATION

• Rarely done for benign


lesions

• Potential invasion of
vessels in malignant
tumors.
IMAGING TECHNIQUES ARE
COMPLEMENTARY
IMAGING TECHNIQUES ARE
COMPLEMENTARY

• Sonography is efficient for


superficial tumors and
ganglia, small lesions, well-
well-circumscribed masses
without contact to joint or
bony erosions.

• It will give you the


relationship of the tumour fl

with vessels and nerves


IMAGING TECHNIQUES ARE
COMPLEMENTARY

• MRI will be preferred for


deep, large or infiltrative
lesions

• In case of cortical invasion, or


joint contact

• For vascular malformations


or complex vascular tumours

• For small glomus tumours