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<v ->Welcome back, everybody.

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We're going to continue on with the program

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and discuss a number of diseases that are tumors

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or tumor-like lesions that involve synovium lined joints.

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I'm gonna start with this one.

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I'm starting calling this pigmented villonodular synovitis,

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although later on,

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I'm gonna introduce the more modern terminology

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for this particular process.

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It is a synovial proliferative disorder,

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typically seen most commonly in middle age

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but also seen in the young

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and in the aging.

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With rare exceptions it is monoarticular.

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I've seen a few cases of both knees being involved

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but generally is monoarticular.

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In common with a lot of disorders

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that we'll be talking about,

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the knee is the most common site of involvement.

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Other joints can be involved

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and some are rather frequently.

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Leading to clinical manifestations that can include swelling

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and joint pain and can be associated with a hemarthrosis.

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When you look at this disease radiographically,

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you generally will see

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the soft tissue swelling in prominence.

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But the joint space is usually preserved

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and bone erosions rather infrequent.

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Now I'm gonna show you a case of bone erosions.

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They tend to occur in tight joints.

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The one that comes to mind immediately is PVNS

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when it involves the hip.

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We look for Hemosiderin deposition when we use MR.

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And the same process, although seen

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in joints can occur in tendon sheaths and in bursae

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where I've shown you some examples already.

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The treatment variable.

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We'll talk a bit about that in a few minutes.

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So let's start by showing you a classic example

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of Pigmented Villonodular Synovitis.

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With he hemosiderin deposition

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involving the Synovial membrane, of the knee.

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You can see the low signal

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and the lower arrows.

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I'm showing you examples

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of the pigmented synovial tissue extending into bone.

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So you will get bone erosions.

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In some cases, the pathogenesis of them

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some people believe they extend

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through the nutrient vessels.

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These are two old cases of Pigmented Villonodular Synovitis

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but they show similar findings.

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As you look at the joint lumen

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you see a background of fluid and you see a lot of areas

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feathery and nodular in their appearance

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in both cases, low signal, reflecting Hemosiderin.

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This is an example showing you the extent

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of bone erosions that can occur

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in Pigmented Villonodular Synovitis.

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When it locates within a tight joint.

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In the hip this has been related

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to the appearance of an apple core

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and you can see this particular example taken

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from a good friend of mine, Mark Murphy, who shows in fact

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that apple core appearance related to the extensive erosion

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of the femoral neck, same sort of appearance.

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I'm gonna show you a little later

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in cases of synovial chondromatosis.

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Another example a Pigmented Villonodular Synovitis.

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This is not a tight a joint as the hip

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but in this particular case,

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we were in fact surprised with a degree of bone erosion

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particularly involving the medial femoral condyle.

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And in the bottom images

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you can see the abnormal hemosiderin filled tissue

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that produce these cystic lesions

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within the bone.

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Pigmented Villonodular Synovitis.

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Recently, I learned also when I received this case

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from previous fellows of ours,

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that there can be fat changes within the abnormal Synovium.

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It is suggested that these relate

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to lipid-laden macrophages or foam cells.

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In this example, I'm using the yellow arrows

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to show you the areas of fat within the Synovial membrane

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the black arrows,

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to indicate the areas of hemosiderin deposition.

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So you should not be fooled if you do see areas

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of fat involving the synovial membrane in this disease.

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Now with regard to treatment methods

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because this particular process may recur in 8% to 20%,

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there is a question of how effective is the treatment.

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The types of procedures that are done include arthroscopic

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or openness synovectomy

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and even external and intra-articular radiation.

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In this particular example, the primary disease shown

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in May, 2007 with hemosiderin deposition

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mainly within the Intercondylar notch of the femur.

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And then in the two images on your right

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you can see the recurrence that occurred

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following yttrium synovectomy,

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still with a lot of hemosiderin deposition

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throughout the knee.

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I have not followed a lot

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of these cases following treatment

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but in the few that I have followed

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where recurrences have occurred, there has been a lot

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of hemosiderin deposition within those recurrences.

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And that brings me

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to this new treatment method that has been described.

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This is hot off the press.

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It's an article in skeletal radiology, I believe this month.

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Where they were utilizing a new product

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a colony stimulating factor, one inhibitor

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which is now a prove for youth within the United States.

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And they had a series of cases that they followed

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And generally when they were good results.

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And as you look at these images

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this is a patient who had a good result.

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You see the initial study

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in the left nine months following therapy in the middle.

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And two years later,

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what we see when there is a good result

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at least as reported was a decrease in the amount of fluid

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but an increase in the amount

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of Hemosiderin deposition within the involved joint.

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And you can see that here with all of this, hemosiderin,

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although the degree of joint fluid and high signal

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less than on the original study.

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So be aware because I think you're gonna see more cases

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of this particular treatment method.

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Does malignant transformation occur

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in patients who have PVNS?

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That is a controversial subject.

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And if indeed it occurs,

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it occurs in frequency clearly less than two or 3% of cases.

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It is said that when it continually recurs

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particularly as the tissue gets more aggressive,

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there is very poor prognosis in those cases.

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Again, taken from a nice article in Radiographics

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by Mark Murphy is the case you see on the right,

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showing you recurrent PVNS of the knee

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and also in the bottom image shown

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by the asterisk lymph node metastasis.

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So I guess very rarely you may see malignant transformation.