Diagnostic Imaging Pathways - Soft Tissue Mass
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This pathway provides guidance on the imaging of adult patients with a soft tissue mass.
Date reviewed: August 2013
Date of next review: 2017/2018
Published: August 2013
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Soft Tissue Haemangioma Image 1 (Plain Radiograph): Punctate calcifications are present in the region of the right wrist and distal forearm (arrowheads), consistent with a soft tissue haemangioma. |
| 2 |  |
Myxoid Liposarcoma Image 2 (Magnetic Resonance Imaging): Myxoid liposarcoma of the right buttock. |
| 3a |  |
Myxoid Liposarcoma
Image 3a: Resection of a large soft tissue liposarcoma showing a circumscribed fatty mass, well demarcated from the surrounding fat. |
| 3b |  |
Image 3b (H&E, x2.5) and 3c (H&E, x25): Histological sections of a myxoid liposarcoma showing sheets of multivacuolated lipoblasts with atypical nuclei (blue arrows) and interspersed arborising thin-walled vessels. |
| 3c |  |
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Teaching Points
Teaching Points
- The percentage of soft tissue masses that are malignant is small, but delay in diagnosis at presentation is a significant cause of morbidity for tumours such as sarcoma
- Initial evaluation of a soft tissue mass is clinical
- Ultrasound is an important initial imaging technique to rapidly confirm the presence of a soft tissue mass and may be diagnostic for classical appearances of some soft tissue lesions, such as cysts and lipomas
- Radiographs are useful to identify osseous or mineralising lesions presenting as an apparent soft tissue mass and complement advanced imaging modalities
- MRI is superior in the assessment of a soft tissue mass
- If a soft tissue mass doesn’t demonstrate tumour-specific features on MRI, or cannot be characterised as a benign entity, the patient should undergo biopsy to exclude malignancy, taking into account lesion accessibility and patient comorbidities 2
lesion
Lesion Characterisation
- Features that suggest a possible malignant lesion include
- Size >5cm
- Deep lesion
- Firm consistency
- Solid or mixed structure
- Large, deep lipomatous masses can be diagnosed with a MRI. Most other lesions, particularly those >4cm, will require histological evaluation with biopsy to confirm the diagnosis
us
Ultrasound
- Ultrasound is often used as a first imaging technique to confirm or exclude the presence of a soft tissue mass due to high negative predictive value, availability, low cost and ability to visualise multiple coexisting masses 3
- Useful in distinguishing
- Cystic from solid masses
- Anatomical relationships to adjoining structures, e.g. communication with the joint
- Vascularity of lesions (using colour or power Doppler)
- One prospective German study categorised tumour groups based on patterns of echotexture (homogenous hyperechoic, homogenous hypoechoic, heavily inhomogeneous) and vascularity to detect soft tissue sarcomas and aggressive benign lesions with a reported 94.4% sensitivity, 79.7% specificity and 89.7% accuracy 4
- Vascularity on doppler ultrasound alone is of limited value in differentiating benign from malignant tumours 5
- For some benign soft tissue masses (e.g. lipomas, cysts, abscesses and foreign bodies), ultrasound findings may be sufficient to obviate the need for further imaging 3
- An indeterminate study or prompts further study with MRI
- Promising as a rapid clinical and imaging triage tool of clinically suspicious soft tissue masses, allowing prompt patient reassurance or effective fast tracking to MRI +/- biopsy 6
xray
Plain Radiography
- Non-specific in soft tissue lesion diagnosis and should be considered a useful adjunct to interpretation with other modalities, including MRI or ultrasound, in most situations
- May be assessed for 1
- Involvement of skeletal structures, indolent or aggressive remodelling of bone
- Soft tissue mineralisation or ossification. e.g. Mature ossification in soft tissue, characteristic zonal patterns of mineralisation (myositis ossificans), phlebolith cluster or punctuate calcifications (haemangioma), hazy calcification (gout)
- Distortion of tissue planes
- Radiolucent fatty areas
- Radiolucent foreign bodies
- Useful to track development of myositis ossificans, however MRI or CT may still be needed to evaluate extent of soft tissue injury 7
- Plain radiography of the symptomatic area is the initial investigation of choice for bone pain or suspected primary bone lesion 8
- If radiographic features are of a definitively benign bone lesion, further imaging may not be necessary unless further anatomic information is required, there is concern of secondary complications (such as pathological fracture) or surgery is contemplated 8
mri
Magnetic Resonance Imaging (MRI)
- Preferred advanced imaging modality for evaluation of soft tissue masses due to superior soft tissue contrast. It is used to evaluate soft tissue masses that are not adequately characterised on ultrasound or plain radiography
- Comparable detection of cortical bone involvement to CT9-12 with the advantage of determination of extent of marrow involvement 13
- Aids in tumour characterisation and staging, detection of neurovascular involvement, identification of tumour necrosis and preoperative planning 1,2,9,11,14-21
- One prospective study of MRI in 548 consecutive patients with soft tissue tumours and soft tissue tumour-like lesions reported 19
- High accuracy in the differentiation of malignant from benign lesions (93% sensitivity, 82% specificity and 85% accuracy)
- High specificity and accuracy in phenotype characterisation but poor and moderate sensitivity in malignant and benign lesions respectively (better in lesions of fatty origin, worse in fibrous tumours)
- Poor correlation between specific MRI diagnosis and histological result - the proposed MRI diagnosis was only correct 50% of the time, highlighting the importance of progression to biopsy in indeterminate masses
ct
Computed Tomography (CT)
- Role has largely been replaced by MRI, but may be useful in
- Assessing patients where radiography does not adequately show the pattern of mineralisation 22,23
- Where MRI is not available or when patients are unable to have an MRI for technical reasons
- May be the preferred imaging modality with tumours in the abdominal or chest wall where motion artefact can create suboptimal imaging with MRI 9,17
- Dual energy CT may be used to noninvasively diagnose and monitor gouty tophi or calcium crystal deposits by analysis of the chemical composition of the scanned materials 24-26
- Although MRI is widely accepted as being superior to CT in the evaluation of soft tissue tumours, one study of 133 patients with primary soft tissue tumours reported no significant difference between CT and MRI in determining tumour size and involvement of surrounding structures 10
pet
Positron Emission Tomography (PET)
- May have a complementary role in the assessment of soft tissue masses in diagnosis, grading, biopsy planning, staging, restaging and evaluating response to therapy
- FDG-PET/CT has a reported 80% sensitivity, 68.4 specificity and 75% diagnostic accuracy in differentiating malignant from benign soft tissue tumours compared to surgical biopsy as the gold standard, although there were many false positive and false negative lesions 27
- A recent metaanalysis with methodological limitations reported a pooled 91% sensitivity, 85% sensitivity and 88% diagnostic accuracy of FDG-PET in the detection of sarcomas. FDG-PET was able to discriminate between sarcomas and benign tumours and low and high grade sarcomas, but there is a lack of studies that assess its ability to differentiate between benign tumours and low grade sarcomas 28
- Benz et al (2010) demonstrated a correlation with sarcoma grade and 18F-FDG uptake by PET, which has implications for sarcoma grading and biopsy planning to increase diagnostic yield 29
- FDG-PET and PET/CT have a pooled sensitivity 96% (91-99%) and pooled specificity 92% (87-96%) in the diagnosis of Ewing sarcoma family tumours on recent metaanalysis, superior to bone scintigraphy and MRI in detection of osseous metastases 30
- PET scanning has a high radiation dose. It has been used mainly for evaluating metastatic disease and follow-up of treated lesions. 7 It may be useful in determining sites with highest biological activity for biopsy
biopsy
Biopsy
- If a soft tissue mass doesn’t demonstrate tumour-specific features on MRI, or cannot be characterised as a benign entity, the patient should undergo biopsy to exclude malignancy, taking into account lesion accessibility and patient comorbidities 2
- There is a paucity of evidence as to when a biopsy of a soft tissue mass is indicated. In the absence of evidence-based data, a biopsy is suggested whenever a mass has biologic activity and further medical or surgical treatment will be based on that result 32
References
References
Date of literature search: March 2013
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Wu JS, Hochman MG. Soft-tissue tumors and tumorlike lesions: a systematic imaging approach. Radiology. 2009;253(2):297-316. (Review article)
- Papp DF, Khanna AJ, McCarthy EF, Carrino JA, Farber AJ, Frassica FJ. Magnetic resonance imaging of soft-tissue tumors: determinate and indeterminate lesions. J Bone Joint Surg Am. 2007;89 Suppl 3:103-15. (Review article)
- Smith S, Salanitri J, Lisle D. Ultrasound evaluation of soft tissue masses and fluid collections. Semin Musculoskelet Radiol. 2007;11(2):174-91. (Review article)
- Schulte M, von Baer A, Schultheiss M, Scheil Bertram S. Classification of solid soft tissue tumours by ultrasonography. Ultraschall Med. 2010;31(2):182-90. (Level II evidence)
- Griffith JF, Chan DPN, Kumta SM, Chow LTC, Ahuja AT. Does Doppler analysis of musculoskeletal soft-tissue tumours help predict tumour malignancy? Clin Radiol. 2004;59(4):369-75. (Level III evidence)
- Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultrasound for initial evaluation and triage of clinically suspicious soft-tissue masses. Clin Radiol. 2009;64(6):615-21. (Level III evidence)
- Expert panel on musculoskeletal imaging:, ACm Z, Weissman BN, Kransdorf MJ, Adler R, Appel M, et al. ACR appropriateness criteria: soft tissue masses. American College of Radiology; 2012 [cited 2013 April 1]. (Evidence based guidelines)
- Expert Panel on Musculoskeletal Imaging:, Morrison W, Zoga A, Daffner RH, Weissman BN, Bancroft L, et al. ACR appropriateness criteria: primary bone tumours. American College of Radiology; 2009 [cited 2013 April 1]. (Evidence based guideline) View the reference
- Jelinek JS, Kransdorf MJ, Shmookler BM, Aboulafia AJ, Malawer MM. Liposarcoma of the extremities: MR and CT findings in the histologic subtypes. Radiology. 1993;186(2):455-9. (Level III evidence)
- Panicek DM, Gatsonis C, Rosenthal DI, Seeger LL, Huvos AG, Moore SG, et al. CT and MR imaging in the local staging of primary malignant musculoskeletal neoplasms: report of the Radiology Diagnostic Oncology Group. Radiology. 1997;202(1):237-46. (Level II evidence)
- Weekes RG, Berquist TH, McLeod RA, Zimmer WD. Magnetic resonance imaging of soft-tissue tumors: comparison with computed tomography. Magn Reson Imaging. 1985;3(4):345-52. (Level III evidence)
- Elias D, White L, Simpson D, Kandel R, Tomlinson G, Bell R, et al. Osseous invasion by soft-tissue sarcoma: assessment with MR imaging. Radiology. 2003;229(1):145-52. (Level II evidence)
- White L, Wunder J, Bell R, O'Sullivan B, Catton C, Ferguson P, et al. Histologic assessment of peritumoral edema in soft tissue sarcoma. Int J Radiat Biol Phys. 2005;61(5):1439-45. (Level IV evidence)
- Toirkens J, De Schepper A, Vanhoenacker F, Van Dyck P, Gielen J, Creytens D, et al. A comparison between histopathology and findings on magnetic resonance imaging of subcutaneous lipomatous soft-tissue tumors. Insights Imaging. 2011;2(5):599-607. (Level III evidence)
- Datir A, James SLJ, Ali K, Lee J, Ahmad M, Saifuddin A. MRI of soft-tissue masses: the relationship between lesion size, depth, and diagnosis. Clin Radiol. 2008;63(4):373-8. (Level II/III evidence)
- Vanel D, Shapeero LG, De Baere T, Gilles R, Tardivon A, Genin J, et al. MR imaging in the follow-up of malignant and aggressive soft-tissue tumors: results of 511 examinations. Radiology. 1994;190(1):263-8. (Level III evidence)
- Cohen EK, Kressel HY, Perosio T, Burk DL, Dalinka MK, Kanal E, et al. MR imaging of soft-tissue hemangiomas: correlation with pathologic findings. AJR Am J Roentgenol. 1988;150(5):1079-81. (Level III evidence)
- Crim JR, Seeger LL, Yao L, Chandnani V, Eckardt JJ. Diagnosis of soft-tissue masses with MR imaging: can benign masses be differentiated from malignant ones? Radiology. 1992;185(2):581-6. (Level III evidence)
- Gielen JLMA, Sciot R, De Schepper A, Vanhoenacker F, Parizel P, Wang X, et al. Accuracy of MRI in characterization of soft tissue tumors and tumor-like lesions. A prospective study in 548 patients. Eur Radiol. 2004;14(12):2320-30. (Level II evidence)
- Liu Q-Y, Li H-G, Chen J-Y, Liang B-L. Correlation of MRI features to histopathologic grade of soft tissue sarcoma. Ai Zheng. 2008;27(8):856-60. (Level III evidence)
- Berquist TH, Ehman RL, King BF, Hodgman CG, Ilstrup DM. Value of MR imaging in differentiating benign from malignant soft-tissue masses: study of 95 lesions.. AJR Am J Roentgenol. 1990;155(6):1251-5. (Level II evidence)
- Pettersson H, Gillespy T, Hamlin DJ, Enneking WF, Springfield DS, Andrew ER, et al. Primary musculoskeletal tumors: examination with MR imaging compared with conventional modalities. Radiology. 1987;164(1):237-41. (Level III evidence)
- Tehranzadeh J, Mnaymneh W, Ghavam C, Morillo G, Murphy BJ. Comparison of CT and MR imaging in musculoskeletal neoplasms. J Comput Assist Tomogr. 1989;13(3):466-72. (Level III evidence)
- Dalbeth N, Choi HK. Dual-energy computed tomography for gout diagnosis and management. Curr Rheumatol Rep. 2013;15(1):301. (Review article)
- Choi H, Burns L, Shojania K, Koenig N, Reid G, Abufayyah M, et al. Dual energy CT in gout: a prospective validation study. Ann Rheum Dis. 2012;71(9):1466-71. (Level IV evidence)
- Manger B, Lell M, Wacker J, Schett G, Rech J. Detection of periarticular urate deposits with dual energy CT in patients with acute gouty arthritis. Ann Rheum Dis. 2012;71(3):470-2. (Level III evidence)
- Shin D-S, Shon O-J, Han D-S, Choi J-H, Chun K-A, Cho I-H. The clinical efficacy of (18)F-FDG-PET/CT in benign and malignant musculoskeletal tumors. Ann Nucl Med. 2008;22(7):603-9. (Level II evidence)
- Bastiaannet E, Groen H, Jager PL, Cobben DCP, van der Graaf WTA, Vaalburg W, et al. The value of FDG-PET in the detection, grading and response to therapy of soft tissue and bone sarcomas; a systematic review and meta-analysis. Cancer Treat Rev. 2004;30(1):83-101. (Level II evidence)
- Benz M, Dry S, Eilber F, Allen Auerbach M, Tap W, Elashoff D, et al. Correlation between glycolytic phenotype and tumor grade in soft-tissue sarcomas by 18F-FDG PET. J Nucl Med. 2010;51(8):1174-81. (Level II evidence)
- Treglia G, Salsano M, Stefanelli A, Mattoli MV, Giordano A, Bonomo L. Diagnostic accuracy of 18F-FDG-PET and PET/CT in patients with Ewing sarcoma family tumours: a systematic review and a meta-analysis. Skeletal Radiol. 2012;41(3):249-56. (Level I/II evidence)
- Kransdorf MJ, Jelinek JS, Moser RP, Jr. Imaging of soft tissue tumors. Radiol Clin North Am. 1993;31(2):359-72. (Review article)
- Rougraff B, Aboulafia A, Biermann JS, Healey J. Biopsy of soft tissue masses: evidence-based medicine for the Musculoskeletal Tumor Society. Clin Orthop Relat Res. 2009;467(11):2783-91. (Evidence based guidelines)
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