Soft-tissue sarcoma mimicking large haematoma: a report of two cases and review of the literature

Tumor-like Lesions of Bone and Soft Tissues and Imaging Tips for Differential Diagnosis

In the musculoskeletal system, tumor-like lesions may present similar imaging findings as bone and soft tissue tumors and can be defined as tumors on radiologic examinations. Misinterpretation of the imaging findings can lead to inappropriate clinical management of the patient.There is still some debate regarding the pathophysiology and origin of tumor-like lesions that include congenital, developmental, inflammatory, infectious, metabolic, reactive, posttraumatic, post-therapeutic changes, and some miscellaneous entities causing structural changes. Although tumor-like lesions are historically defined as non-neoplastic lesions, some of them are classified as real neoplasms.We discuss a spectrum of entities mimicking tumors of bone and soft tissues that include various non-neoplastic diseases and anatomical variants based on imaging findings.

Clinical features of soft tissue sarcoma presenting intra-tumour haematoma: case series and review of the literature

INTRODUCTION

Intra-tumour haematoma is an uncommon clinical presentation in malignant soft tissue tumours. This study aimed to highlight the clinical features of patients with soft tissue sarcomas with intra-tumour haematoma.

METHODS

The patient group was composed of eight men and one woman aged between 29 and 83 years (mean 44.0 ± 20.8). The average follow-up was 29.8 months. Clinical information, including clinical features, radiological information and treatment course, was retrospectively investigated.

RESULTS

Tumours were predominantly located in the chest wall and thigh, and average diameter was 10.3 cm. Six patients underwent needle biopsy with ultrasound sonography, and three underwent an open biopsy. Histological diagnoses indicated that all tumours were high grade, three of which were undifferentiated pleomorphic sarcomas, three synovial sarcomas, two pleomorphic liposarcomas, one a leiomyosarcoma and one a malignant peripheral nerve sheath tumour. The median diagnostic delay time was 3.0 months. Magnetic resonance imaging (MRI) indicated a haematoma area <25 % in three, 25-50 % in four and 50 % two. A wide resection was performed in eight patients, and radiotherapy was administered to one patient for the initial local treatment of a primary tumour. Local recurrence was detected in four patients, whilst five developed lung metastases. The five-year survival rate was 57.1 % and median survival 34.0 months.

CONCLUSIONS

Soft tissue sarcomas with intra-tumour haematoma presented with locally aggressive and highly metastatic behavior, consistent with high-grade tumours.

Chronic Expanding Hematoma in the Dorsal Cervicothoracic Region as a Long-Term Complication of Retained Bullet Fragments: Case Report

Chronic expanding hematoma is a rare pathology, which has not been previously described as a complication of gunshot injury with retained bullet fragments. Because of the similar characteristics of chronic expanding hematoma to malignancy, it can present a diagnostic challenge for clinicians. Imaging and biopsy evaluation is needed to reach a conclusive diagnosis and implement appropriate treatment. In this case report, we will discuss the development, diagnosis, and management of a chronic superficial cervicothoracic mass in a patient who presented 30 years post-gunshot injury with retained bullet fragments. 

Sarcoma the great "masquerader" hematoma/deep vein thrombosis manifestation

INTRODUCTION

The clinical presentation of patients with soft-tissue sarcoma is highly variable. Most patients present with a painless mass, typically one that is increasing in size, and few have systemic symptoms such as fever, weight loss, or malaise. Soft tissue sarcomas can initially present as, or even be misdiagnosed as, deep venous thrombosis (DVT), leading to a late diagnosis.

CASE REPORT

A 51-year-old woman presented to the hospital with complaints of pain and swelling in her left thigh, interpreted as an infected hematoma with an associated deep vein thrombosis and treated accordingly. The patient presented to our emergency department two more times. In the last visit and due to an unresolving clinical scenario a MRI and surgical byopsies were made that confirmed a sarcoma diagnosis.

DISCUSSION

When a patient presents with an expanding, nontraumatic mass simulating a haematoma, several other differential diagnoses should be considered including aneurysm, bleeding tendency, chronic expanding haematoma and soft-tissue sarcoma. The growth of the tumor undetected while being treated for the DVT and then posteriorly for the hematoma, was without a doubt dismal to the patient, so earlier diagnosis would have been preferable.

CONCLUSION

When a patient presents with an unusual history of hematoma in the extremities, it is necessary to consider the possibility of a malignant soft tissue tumor.

Unusual brachial plexus lesion: Hematoma masquerading as a peripheral nerve sheath tumor

Background:

Malignant peripheral nerve sheath tumors (MPNSTs) of the brachial plexus have unique radiographic and clinical findings. Patients often present with progressive upper extremity paresthesias, weakness, and pain. On magnetic resonance (MR) imaging, lesions are isointense on T1-weighted and hyperintense on T2-weighted sequences, while also demonstrating marked enhancement on MR studies with gadolinium diethylenetriamine pentaacetic acid. On the basis of their characteristic MR imaging features and rapid clinical progression, two brachial plexus lesions proved to be organizing hematomas rather than MPNST.

Methods:

A 51-year-old male and a 31-year-old female were both assessed for persistent and worsened left-sided upper extremity pain, paresthesias, and weakness. In both cases, the MR imaging of the brachial plexus demonstrated an extraspinal enhancing lesion located within the left C7–T1 neuroforamina.

Results:

Although the clinical and radiographic MR features for these 2 patients were consistent with MPNSTs, both lesions proved to be benign organizing hematomas.

Conclusions:

These two case studies emphasize that brachial plexus hematomas may mimic MPNSTs on MR studies. Accurate diagnosis of these lesions is critical for determining the appropriate management options and treatment plans. Delaying the treatment of a highly aggressive nerve sheath tumor can have devastating consequences, whereas many hematomas resolve without surgery. Therefore, if the patient has stable findings on neurological examination and a history of trauma, surgical intervention may be delayed in favor of repeat MR imaging in 2–3 months to re-evaluate the size of the mass.

Differentiation of Benign Fluid Collections from Soft-Tissue Sarcomas on FDG-PET/CT

OBJECTIVE

To assess the diagnostic performance of (18)F-FDG PET-CT in differentiating soft tissue sarcomas (STSs) from benign fluid collections (BFs).

MATERIALS AND METHODS

Four readers independently reviewed 100 lesions on (18)F-FDG PET-CT and subjectively classified each lesion as an STS or BF and scored the spatial pattern of (18)F-FDG avidity (SP) of each on a 4-point ordered scale (thin, moderate, thick, solid).

RESULTS

Subjective assessment by readers allowed sensitive (91%-98%) differentiation of STSs from BFs, with lower specificity (59%-91%). The STSs had significantly higher SUVmax (median 10.7, range: 2.0-33.7) than BFs (median 2.8, range: 1.1-12.3). Reader agreement in assessment of SP had average κ = 0.61 (range 0.46-0.70). Classification of thick or solid SP as STS yielded an inter-reader averaged sensitivity and specificity of 69% and 98%, respectively. The presence of thick or solid SP resulted in 14.1-fold increase in partial odds of STS. Each unit increase in SUVmax resulted in 1.35-fold increase in partial odds of STS. The receiver operating characteristic (ROC) curves and 95% intervals for SUVmax alone and SUVmax + SP overlapped. The average subjective assessments for the four readers and estimated performance of using SP alone were both contained within the 95% intervals of the two ROC curves.

CONCLUSIONS

(18)F-FDG PET-CT is a sensitive modality for differentiating STSs from BFs. SUVmax and SP are significantly associated with STS. Classification schemes based upon SUVmax alone or augmented with SP can be useful for distinguishing STS from BF.

Chronic expanding hematoma extending over multiple gluteal muscles associated with piriformis syndrome

We report on a patient with an unusual, slowly enlarging hematoma of the left buttock. A 62-year-old man presented with a 6-year history of an enlarging mass of the left buttock. He had first noted the mass 6 years earlier and had had sciatica of the left lower limb for the last 2 months. He denied any history of antecedent trauma. The lesion extended over 3 gluteal muscles (the gluteus medius, gluteus minimus, and piriformis). On microscopic examination, the lesion showed typical signs of chronic expanding hematoma. The sciatica was relieved after surgical removal of the lesion. The lesion had not recurred at the last follow-up 4 years after the operation. The present case suggested that chronic expanding hematoma can extend into multiple muscles due, perhaps, to long-term growth and the anatomical and functional conditions of the affected muscles. Our case also suggests that chronic expanding hematoma can be a cause of piriformis syndrome.

Acutely calcified hematoma mimicking a displaced medial epicondyle fracture

We present an interesting and unusual case of an acutely calcified pin-site infection hematoma mimicking a displaced cartilaginous medial epicondyle, in a child with a Gartland type III fracture. The treatment of such pathology could be confusing and may interfere with the correct clinical decision-making process. To our knowledge, this is the first presentation of such a case.