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today. We're honored to join show Welcome,

0:43

Dr. Stephen J pomerance for a

0:46

lecture on soft tissue masses on MRI, Dr. Pomerance

0:49

is the CEO and medical director of ProScan Imaging

0:52

chair of Naples, Florida Community Hospital Network and the

0:55

founder of modality formerly MRI online. He's authored

0:58

numerous medical textbooks in MRI including the MRI total

1:01

body.

1:01

Us Dr. Pomerance is an avid conference lecture

1:04

in chair Fellowship training programs in Mr. And

1:07

Advanced Imaging.

1:08

At the end of the lecture join Dr. Pomerance in a Q&A

1:11

session where he will address questions you may have on today's topic.

1:14

Please remember to use the Q&A feature to submit those

1:17

questions and we'll get to as many as we can before our

1:20

time is up.

1:21

With that we are ready to begin today's lecture Dr. Pomerance.

1:24

Please take it from here.

1:27

All right. I'm good to go.

1:30

Welcome modality MRI online

1:33

aficionados members and other we're talking

1:36

introduction to MRI of

1:39

soft tissue masses. And for once this is

1:42

an introductory lecture, but that doesn't mean that it's simple.

1:45

Let's start out with a

1:48

general approach.

1:50

To soft tissue

1:53

masses and I began with

1:56

you know, the patient's age juveniles get different

1:59

diseases than 90 year olds the gender and the

2:02

patient's name and ethnicity.

2:04

Are we dealing with a larger small part of

2:08

the body or a larger small muscle group?

2:11

Position wise where where is this abnormality? Is

2:14

it central or is it is it eccentric?

2:17

What compartment doesn't lie in is it

2:20

cortical? Is it periosteal? Is it muscular? Is it subcutaneous?

2:23

Is it fascial or is it in

2:26

the skin in the epidermis itself?

2:29

The signal intensity you've got a understand basic

2:33

pulsing sequences and understand various disorders.

2:37

Does it have a wider narrow zone of transition just like you

2:40

would assess in the skeleton. What's the

2:43

internal character of it? Is it homogeneously white

2:46

or is it very heterogeneous on T1

2:49

as might occur with blood?

2:51

What are some of the common lesions that you expect to find

2:54

in the soft tissues? They include lipomas hemangiomas

2:57

7% of all soft tissue neoplastic

3:00

masses schwannomas or ganglion pseudocysts.

3:05

Let's start out with with signal

3:08

and we begin with

3:11

T1 hyperintensity which includes blood fat flow

3:14

and bone marrow. Now, I'm

3:17

starting with these because these are the ones that are more specific T2, hypo

3:20

intensity not intermediate. But

3:23

hypo intensity relative to muscle flow fibrous

3:26

tissue cordicated bone

3:29

Emma citrine acute blood and then there's lossless

3:32

no signal intensity with air then

3:35

you get into gradient Echo Imaging or T2 star

3:38

Imaging in which a signal on

3:41

a T2 is somewhat dark, but it gets even blacker

3:44

and maybe somewhat distorted on the

3:47

gr-e, which is a sign you're dealing

3:50

with blood blood products regime.

3:53

In Mr. We have definitions for assist

3:56

just like we have an ultrasound an ultrasound

3:59

decreased decogenicity well-defined wall.

4:02

Excellent through transmission. Nothing inside.

4:05

Well on MRI, you've got

4:08

to match water signal intensity. You've got to match CSF.

4:12

It cannot have complex internal character

4:15

to it. It should be lower in

4:18

signaled and muscle for if it's not you've got to consider other

4:21

disorders such as complex cysts mix

4:24

so it lesions or lesions with a high

4:27

cytoplasmic to nuclear ratio. If

4:30

it's great on all sequences gray on

4:33

T1 gray on T2, then you must consider

4:36

lesions with high nuclear to cytoplasmic

4:39

ratio for instance. Lymphoma would be

4:42

one such example

4:44

So here's an example of just that.

4:46

T1 fat way to T2 water weighted

4:49

gray dark gray solid but

4:53

on ultrasound a pitfall because you

4:56

have very very tightly packed cells you get the

4:59

impression of a well-defined back wall with through transmission.

5:03

One of the criteria for sonographic cyst

5:07

diagnosis, but in fact, it's a solid

5:10

lesion. It is a lymphosarcoma arising

5:13

from a vein.

5:16

So this one has a very high nuclear to

5:19

cytoplasmic ratio. There's very little water inside. It

5:22

is gray and gray and that is one of the

5:25

characteristics of lymphoma throughout the

5:28

body and this helps differentiate it from

5:31

say a plasma cytoma, which has a higher cytoplasmic

5:34

to nuclear ratio and is

5:37

therefore going to be bright because of its water

5:40

content on T2 Imaging. Let's take a case

5:43

study now.

5:45

This is a radiograph with a big fat thumb.

5:49

And there are these lucencies within the

5:52

skeleton with slight sclerosis. So

5:55

your your challenge.

5:58

On this radiograph and on Mr. Is did this

6:01

abnormality arise from the bone and go

6:04

out or did it arise from the soft tissues and go

6:07

in? It's like belly buttons. Is it in any or

6:10

is it an Audi? So your first

6:13

question is where did the lesion begin and then

6:16

you go through your general checklist. Now this

6:19

was sent by a hand surgeon. So we had a very extensive

6:22

physical examination, which you see

6:25

here and then here is our Mass. This is

6:28

the water. Sorry the fat weighted image. You

6:31

see that the signal intensity is certainly brighter

6:34

than muscle. So it is highly likely

6:37

that there are dilute blood products in this lesion. It

6:40

is much more in the soft tissues than it is in

6:43

the bone. Even though it is producing rare faction

6:46

of bone. And on this water weighted image,

6:49

you see this dark area along the rim, which

6:52

is highlighted even more conspicuously on

6:55

the short axis gradient Echo image.

6:58

You see dark dark and very

7:01

dark down below all signs of

7:04

cinerotic material on a gradient

7:07

Echo image, which is more conspicuous when you

7:10

go from the t2 to the GRE. This is

7:13

what's known as blooming phenomenon. You don't really

7:16

see much on the T1 way to damage but when the darks get

7:19

darker going from T2 to GRE, you're likely

7:22

dealing with chronic blood products and

7:25

you're in the finger, you know lesions in

7:28

the finger are epidermal giant cell tumor

7:31

of tendon sheath and others, but here you would absolutely

7:34

pick when you combine your knowledge of where

7:37

a disease occurs and it's signal intensity gcts

7:40

is the diagnosis. There's the

7:43

finger on macroscopic inspection and there

7:46

is the lesion coming out. This is

7:49

not a product of the dissection. This

7:52

is actually blood products and citarotic

7:55

material throughout this

7:58

and making the diagnosis histologically specific

8:01

on Mr.

8:03

Now, let's turn our attention to specific signals

8:06

in the soft tissues.

8:09

Yes, you do get cartilage lesions in the soft tissues.

8:12

Typically cartilage. Matrix is going to

8:15

be very bright on T2 because of its water

8:18

and proteoglycan content and it may

8:21

or may not contain low signal intensity speckled

8:24

calcific Foci vascular signal

8:27

usually linear or lobulated and

8:30

the flow characteristics vary from Fast flow

8:33

dark to slow Flow White to

8:36

pull blood Ray and

8:39

then you get fibrous lesions the more mature

8:42

the fibrous lesion, the more will differentiated

8:45

the fibrous lesion the blacker the

8:48

signal

8:49

Less well-differentiated the t2

8:52

signal starts to climb then you've

8:55

got blood I'm going to show an example of that now blood in

8:58

the brain is a bit more organized and the body it's more

9:01

heterogeneous with high single intensity

9:04

on T1 due to medhealoglobin staining after two

9:07

or three days and low T2 signal

9:10

intensity after two or three days due to

9:13

the deoxyhemoglobin intracellular effects. However,

9:16

as time goes on you'll still see some

9:19

high T1 signal and this low T2

9:22

signal will convert to high so it'll be high

9:25

and high at about 10 days

9:28

to two weeks air is very very low signal on

9:31

T1 and T2. It's also very

9:34

sliver like or bubbly so shape is helpful

9:37

that I on T1, very low

9:40

on T2 with fat suppression

9:43

water low on T1 high on

9:46

T2, very smooth and matches water.

9:49

Swear in the body. It matches urine it

9:52

matches cerebral spinal fluid. So you use the

9:55

standards that are in the body to make

9:58

comparisons when you're coming up with a diagnosis of

10:01

a simple cyst. It must be lower in

10:05

Signal intensity than adjacent muscle and

10:08

it must match a known water containing

10:11

standard.

10:13

Calcium calcium can be anything it can

10:16

be low. It can contain marrow products so

10:19

it can be high so all bets are off

10:22

there and sometimes it's best to acquire a

10:25

radiograph or a CT to confirm the

10:28

diagnosis of calcification or look at

10:31

the internal character of masses, especially in bone, but

10:34

we're not on bone today. He misitterant low on

10:37

T2, but especially on the t2 star

10:40

radiant Echo fast field

10:43

Echo Flash the gradient

10:46

recall that goes steady state all of those will produce

10:49

blooming so that areas of hemisphere and

10:52

get lower and perhaps maybe even geometrically distorted.

10:57

Here's an example of a simple hematoma as

11:00

a soft tissue Mass from an ankle sprain on

11:03

the T1. There are areas of wax

11:06

on wax off hyperintensity. This

11:09

is non-contrast. These are met hemoglobin

11:12

blood products. This is not as homogeneous and

11:15

tight as you see with made

11:18

hemoglobin staining in brain hematomas, but

11:21

you have to learn to recognize blood in

11:24

the body. It's a little more disorganized and then

11:27

when we get over here on the t2, this is a proton density fat

11:30

suppression on the t2, it's not very black because

11:33

we're in The Chronic or early chronic phase

11:36

of this hematoma. So what was Black on

11:39

T2 is now converted to White so it's mostly

11:42

white on T1 mostly white on

11:45

T2. This is a late Subacute to Chronic hematoma.

11:50

More about signal intensity. Let's turn our

11:53

attention to fat.

11:55

That is ubiquitous. We have fatty tumors.

11:58

We have fatty dysplasia. We have fatty syndromes.

12:01

We have fatty benign lesions malignant lesions syndromes

12:04

and so on T1, bright signal intensity

12:07

is most often fat, but you can see with proteinaceous fluid

12:10

flow metal marrow contrast injected

12:13

agents and Subacute to

12:16

Chronic blood. There's an

12:19

example of a calcaneal lipoma contrasting the

12:22

lipoma with its Central necrotic

12:25

infarctic area. That is more water like

12:28

water inside fat as a

12:31

comparison for signal.

12:33

So more about T1 signal intensity, we're

12:36

going to use Muscle as a reference is

12:39

this signal intensity Mass? Like

12:42

lesion in the thigh lower than muscle?

12:45

I don't know. It's pretty close.

12:48

It's if it's lower than muscle not by a lot and it

12:51

has some very strange gray but

12:54

hard to see septations inside. Here's

12:57

the t2 weighted image. So it's

13:00

low, but it's not low enough to be assist.

13:03

So it could be protonacious fluid. It

13:06

could be blood. It could

13:09

be fibrous. It could be metal. It could be air. It could

13:12

be him a sitter and it could be contrast. It could be cortical bulb, but

13:15

with the t2 signal intensity, we now know that

13:18

whatever this is as a high water

13:21

content. That is likely

13:24

complex.

13:25

So a complex water signal

13:28

intensity Mass has a very broad differential diagnosis,

13:31

but not so much when you're

13:34

in the large muscle group of the thigh. And

13:37

when you have a large lesion, your mind should

13:40

go to unpleasant things like mixoid malignant

13:43

lesions. And this was a

13:46

proven. Myxoid liposarcoma of

13:49

the thigh. Let's do it. Again this time

13:52

T1, that weighted water weighted.

13:55

No way is this T1 weighted

13:58

smooth architectural Mass with

14:01

sharp zone of transition darker than

14:04

muscle. There's some muscle right there. It is

14:07

certainly brighter than muscle. It's bright on T2. It's

14:10

exhibiting some chemical shift effect sitting

14:13

next to fat, but it is not fat. It's proteinaceous

14:16

water. It's located superficially in

14:19

the back between the scapula. So

14:22

knowing the location

14:25

Observing the signal knowing that it's in the

14:28

subcutaneous space there really isn't a differential

14:31

diagnosis and it's hypovascular to

14:34

boot. It is a sebaceous cyst

14:37

and this was a woman. So the gender was

14:40

also appropriate and correct as was the

14:43

location these like to occur in the axillavathize and

14:46

the creases of the body. Let's take another

14:49

one.

14:51

On a T2 weighted Mr. It looks like a water type

14:54

Mass. But when we go to the

14:57

CT the hounds field unit number

15:00

measurement was 35 in no

15:03

way consistent with a simple cyst. It's

15:06

deep within a large muscle area not

15:09

where you would expect a gangly and it doesn't have the

15:12

shape of a Hemangioma. It clearly is. In fact,

15:15

it clearly has water in it so location.

15:19

signal

15:20

and depth it's very very deeply lying right on

15:23

top of the femur. These are all characteristics that

15:26

would make you worry about a myxoid malignant

15:29

process or at least at the very least a

15:32

myxoid tumor.

15:34

And indeed this was a myxoid tumor. This was a

15:37

benign mixoma. It's very hard to tell.

15:41

Sometimes a mixoma from a mixoid malignancy such

15:44

as mixo fibrosarcoma. And

15:47

so resection is often undertaken. You'll

15:50

look at the contrast enhancement characteristics

15:53

to help you but bigsomas have cute boy

15:56

to epithelium they do enhance they are muscular if

15:59

they're benign. They generally do not demonstrate any

16:02

edema and they often fall into differential diagnosis

16:05

of a ganglionoma and

16:08

epidermoid and other water like lesions

16:11

that have a high cytoplasmic to

16:14

nuclear ratio. Let's take another one looks like

16:17

water but it isn't

16:20

It's not pure water. Here's the T1. No way.

16:23

Is that lower in Signal intensity

16:26

to muscle? In fact, it's substantially higher.

16:30

It's in the volar aspect of the finger. This was

16:33

an implantation epidermoid that

16:36

was progressively enlarging over time. It got

16:39

excised. It's proven but just an

16:42

illustration that you don't go down the road

16:45

of assist just because it's smooth just

16:48

because it's bright on T2. It takes so

16:51

much more to make the criteria of

16:54

a simple cyst on Mr.

16:57

more about signal intensity

17:00

Let's talk about T2 dark signal fast

17:03

flow metal air acute blood

17:06

susceptibility hemisitorin.

17:09

Fibrous tissue that's very mature the

17:12

less mature. It is the less low.

17:15

The signal intensity is going to be cortical bone

17:18

tendons ligaments, iatrogenic glass

17:21

and plastic and calcium. Here's

17:24

an example of a mass in

17:27

the proximal pronator teres. It's so

17:30

dark. You can barely see it on the axial

17:33

T2 weighted image, but there it is

17:36

generating. Absolutely. No edema,

17:39

very little Mass Effect

17:42

just simply following The Superficial fascial

17:45

layer of the pronator teres consistent

17:48

with a mature by broma

17:51

and there are a whole host of intermediate and

17:54

high grade fibrous lesions that as you

17:57

climb that ladder this low T2, signal

18:00

will become higher and higher and

18:03

higher so fibrous lesions do not have to

18:06

be uniformly dark unless they are extremely

18:09

mature simple fibromas

18:13

Some additional pearls to help you, you know narrow your

18:16

differential diagnosis. You know, where is

18:19

it? Where is the lesion you have to know the

18:22

entities where they occur and the finger Globus tumor epidermal

18:25

giant cell tumor tendency in the knee pns

18:28

synovial sarcoma various

18:31

cysts of the past and serine or

18:34

the gastrocnemius Bursa gout in

18:37

the popliteal fossa in the forearm epithelioid sarcoma

18:41

pseudotumor or nodular fasciitis in

18:44

the foot by bromitosis foreign bodies.

18:47

And once again synovial sarcoma in

18:50

the toe epidermoid Morton's

18:53

neuroma a callus an adventitial cyst

18:56

and infection and then not listed fibroma of

18:59

tendon sheath of the toe arm Barracks nodes

19:03

cat scratch disease mononucleosis in

19:06

the elbow hemophilic pseudotumored

19:09

doubt, especially in the triceps tend.

19:13

The hip para labral and versal CIS

19:16

and dissection from abdominal pathology including appendicitis

19:19

in the

19:22

thigh malignant fibrocysteocytoma and

19:25

myxoid liposarcoma are two

19:28

of the most important high-grade malignancies that

19:31

occur here and in the scapulous serratus

19:34

anterior region a classic alasto fibroma.

19:38

Dorsi here is gender a woman

19:42

signal

19:43

a snowstorm of intermediate on

19:46

T1 to low signal fibrous-like on

19:49

T2

19:52

adjacent to the ribs deep to

19:55

the serratus near to the scapula location

19:58

gendered signal equals elasto

20:01

fibroma. Dorsi a

20:04

do not touch me form of low grade

20:07

desmoid lesion that will recur if

20:10

you resected with a high incidence of bilaterality. So

20:13

these we often watch instead of

20:16

aggressively remove.

20:19

Let's talk about fibromatosis since we stumbled on

20:22

elasto fibroma. Dorsi. There are

20:25

specific locales for various fibromatosis syndromes

20:28

and these include the

20:31

hands and doobie Trends contracture and the feet

20:34

in leaderhauser's disease.

20:36

Older patients have it in the hands younger patients

20:39

in the foot tend to be flatter in the hand

20:42

more nodular in the foot the higher

20:45

the signal intensity on T2.

20:49

The more likely recurrence and the higher incidence of

20:52

mitotic figures.

20:54

So these if they're going to be resected have to

20:57

be resected with a very broad area

21:00

of transition.

21:03

And then there is a familial tendency bilateral in

21:06

the hand 50% of the time in all individuals

21:09

and bilateral in the feet 19% of

21:12

the time you must exercise as

21:15

I mentioned with a wide zone of transition of at

21:18

least five millimeters or more. There are

21:21

current rate is very high 50% more frequent

21:24

and man Caucasians with a history of by the way

21:27

epilepsy 5% of these individuals will

21:30

have knuckle pad fibromatosis and

21:33

20% of people with leader houses disease

21:36

in the foot will have to be

21:39

trans contracture. So this can be a systemic condition. It is

21:42

a condition with a genetic predilection.

21:46

Here's an example of plantar fibromatosis.

21:49

And even those these are described as

21:52

non-aggressive fibromatosis because they don't

21:55

metastasize when they get this big in the

21:58

medial cord of the planter aspect of

22:01

the foot and they demonstrate this musculo upon

22:04

neurotic wavy line sign this

22:07

serpentionist internal sign. They have

22:10

a very high recurrence rate, especially when

22:13

they're large and especially when they're not very dark

22:16

or black or dark gray on

22:19

T2 Imaging so the lighter they get the higher

22:22

the recurrence rate in this patient with leader

22:25

housers syndrome.

22:27

There's a unrelated condition but

22:30

it has the name fibrous in it.

22:33

This is a fibrous reaction. This is

22:36

actually an entrapment neuropathy of the foot occurring

22:39

between M3 and M4 the

22:42

third and fourth metatarsals. It looks like a little peanut.

22:45

It's dark on T2. No, this

22:48

is Perry neural fibrosis the so called

22:51

Morton's neuroma that occurs between metatarsal

22:54

heads due to friction, especially in

22:57

those that where tight-fitting shoes and don't forget

23:00

you're often going to see fibrous calluses

23:03

under the fifth and under the first metatarsal

23:06

and just about everybody and sometimes these

23:09

calluses will hollow out and fill with

23:12

fluid developing what's known as an adventitial cyst

23:15

another example of where local can

23:18

really help you.

23:22

In the old days if you had epitrochlear adenopathy

23:25

you'd think about tuberculosis or syphilis.

23:28

That's why they shook your hand and grabbed your

23:31

arm. But today if you see a petrochlear adenopathy, you

23:34

should think about mononucleosis and Cat

23:37

Scratch disease, especially if it's it's inflammatory

23:40

with a dirty peripheral rim

23:43

to it like this area of lymphadenitis and

23:46

almost pathognic diagnosis in

23:49

a young person, especially if they have a cat

23:52

at home.

23:54

Another example of signal and this time signal and shape

23:57

as well as location it are

24:00

these areas of linear.

24:03

Area areas of lossless signal intensity

24:06

now, sometimes they're linear in tight compartments.

24:09

Sometimes they're bubbles but this is

24:12

air or gas. And if you have any doubt get an

24:15

x-ray get a CT, there's no shame in

24:18

doing that whatsoever. This is

24:21

a patient with a flesh eating bacterial infection with

24:24

fournier's Gang Green. You can see the CT

24:27

with air in the in the perineum.

24:31

Another example of signal intensity that's a

24:34

bit confusing is Illustrated in this case x-ray

24:37

Red by a neuroradiologist

24:40

as a fractured osteochondroma in which

24:43

he said this was all blood that was

24:46

incorrect. None of it is blood. He

24:49

was fooled by the

24:51

Hyperintense signal on T1 compared to

24:54

muscle and the Very hyperintense signal on

24:57

T2, which is the signal

25:00

intensity of cartilage Matrix. This

25:03

is all ossification right here. So this

25:06

is what cartilage Matrix looks like now I

25:09

admit it's a bone lesion, but it's protruding

25:12

into the soft tissues, but you can get primary heartilaginous Matrix

25:16

in the soft tissues and you can get parastale chondroit

25:19

lesions. They're protrude

25:22

into the soft tissues.

25:25

Let's turn our attention now to a few signs of

25:28

soft tissue masses the ball on

25:31

a string also known as the tetherball sign aneurysm and

25:34

neural tumor the tail sign where one

25:37

end of the lesion communicates with a tendon

25:40

or a joint the ganglion pseudo cyst concentric rings

25:44

of high and low signal and aneurysm speckled

25:47

areas of signal intensity representing

25:50

fat schwannoma or flow voids

25:53

Lomas tumor or even vascular

25:56

lesions such as avms or

25:59

certain types of hemangiomas the wavy

26:02

line or band sign which you briefly saw

26:05

in plantar fibromatosis can also

26:08

be seen in Des Moines. Not dermoid Des

26:11

Moines.

26:12

the ball on a string sign

26:15

here is a short axis view. If you

26:18

look very carefully there's a little bit of speckled signal

26:21

intensity here. I don't see a string yet.

26:24

I see around object adjacent to

26:27

the radius with high signal margin gray

26:30

in the middle. But where's our ball on the string?

26:33

It is right here and there is our string.

26:36

It's the radial nerve. There is

26:39

our ball. It's a radial nerve schwannoma

26:42

easy peasy. It was excised. It

26:45

protruded in the forearm. The tail

26:48

sign here is a ganglion pseudocyst

26:51

as our example of a tail sign these arise

26:54

from tendons or capsules, but some

26:57

other lesions that can give you a tail sign or aneurysms

27:00

neural tumors and some Verso

27:03

synovial cysts. The ganglion

27:06

pseudosist is just one lesion that

27:09

may arise from attendant. This also includes gout xanthoma

27:12

amyloid and gentle tumor ten, and

27:15

she

27:15

Is our ganglion pseudosis one of the most common

27:18

soft tissue non neoplastic masses

27:21

that we find in individuals. There

27:24

is our Mass. It is lower and Signal

27:27

intensity than muscle that's comforting. It's very

27:30

smooth without nodularity or mass inside

27:33

it that's very comforting and we

27:36

see the tail headed up towards the infra patellar

27:39

tendon that is also very comforting

27:42

the tail sign of ganglion pseudocyst.

27:45

And remember a ganglion

27:48

is histologically identical to a meniscal

27:51

cyst or a parallel cyst. They are

27:54

all pseudocysts with a fibrous Rim.

27:57

They do not have a cuboidal epithelial lining

28:00

or an epithelial lining of any kind as

28:03

might occur with a myxoid tumor.

28:06

So these are easily distinguished from tumors by

28:09

the pathologist but a parallel cyst a

28:12

meniscal cyst and a ganglion pseudocyst is

28:15

an MR radiographic diagnosis is another

28:18

sign the speckled signs speckling

28:21

on T2 and fatty speckling

28:24

on T1 in a large enr Eminence.

28:27

Schwannoma. Here's our

28:30

schwannoma on T2. Look at how bright it is. There are

28:33

the little Speckles of fat on the short axis

28:36

t-1 weighted image here. It is coming out attached

28:39

to a branch of the median nerve

28:42

and that speckling of fat is produced by

28:45

the Antony B cell component of the

28:48

schwannoma.

28:50

Another sign the concentric ring sign

28:53

of an aneurysm.

28:56

There is the thrombosis in the middle. There's a ring

28:59

of low signal intensity. There's another ring of

29:02

high signal intensity and there's the peripheral rim

29:05

of the the aneurysm and

29:08

the vessel. So we've got wall we've got thrombus. We've

29:11

got fibrous tissue and hemisinter and and then

29:14

we've got more thrombus the concentric ring sign

29:17

indicating. You've got a vascular lesion a

29:20

radial artery aneurysm that was thrombosed.

29:23

So that's a segue into

29:26

vascular lesions.

29:27

We've got AVM and Venus malformations.

29:30

These are malformations. Not

29:33

tumors. They're anomalies. They

29:36

can have fast flow or flow void. They can

29:39

have slow flow.

29:41

They can have pulled blood slow flow bright

29:44

low void dark. Ooh blood

29:47

gray, and then you've got hemangiomas hemangiomas

29:50

or neoplasms.

29:53

They are hormonally responsive. I've seen

29:56

them grow during a pregnancy three or four

29:59

times their size their estrogen responsive. They

30:02

generate gray intermediate T1. Signal.

30:05

They're bright on T2. They're often superficial.

30:08

They may contain fat again. They they are

30:11

neoplasms and they're fairly bright and

30:14

they look like little raisins on the Mr.

30:17

Study. Then you've got the Globus tumor

30:20

which demonstrates flow voids with speckled areas

30:23

of low signal intensity.

30:26

And you've also got the Carotid body tumor or

30:29

the chemo dictoma that produces splitting of

30:32

the internal and external carotid artery and then finally barracks

30:35

in which there's either slow flow or no

30:38

flow and it's attached to a vein and sometimes

30:41

it's helpful to get your ultrasound out

30:44

and use color flow Doppler to see

30:47

how much pool blood arterial flow and Venus

30:50

flow you have so one of these

30:53

Is going to be an ABM. One of them

30:56

is going to be a superficial Hemangioma and one of them is

30:59

going to be a varics what you choose.

31:02

On the left is flow void.

31:06

Fast flow very wavy very deep

31:09

all characteristics of an a b

31:12

m.

31:14

On the other hand here. We have a mixed Venus capillary

31:17

and cavernous He-Man geoma

31:21

this part of it. Looks like a hockey puck. It is

31:24

gray for it is pulled blood. There's a

31:27

flea right there. And then on the right, we've

31:30

got a vein with a valve and it's Associated

31:33

varic. So simple simple and

31:36

easy diagnosis to differentiate the

31:39

three, here's what I mean by those little raisins and

31:42

this example of a Venus

31:45

Hemangioma of the lateral thigh. Maybe

31:48

these are Big raisins or little grapes a

31:51

different patient with a lesion in the

31:54

distal medial thigh and yet a third one remember he

31:57

man geoma seven percent of all soft tissue

32:00

neoplasms pretty darn common and there

32:03

are raisins or small grapes. They're intermediate on

32:06

T1 due to pull blood and they

32:09

are bright on the water weighted image with a fleabolith right

32:12

there in the tibial.

32:14

a region

32:16

arterial venous malformations occur at Birth but

32:19

they don't usually evolve they enlarge with trauma. They

32:22

enlarge with puberty with pregnancy. They

32:25

can also get bigger due to failed dietrogenic

32:28

events at attempts at

32:31

curing essential lesion. You've got the arterial venous

32:34

fistula, which is induced frequently by trauma,

32:37

usually a single large communicating trauma

32:40

it can occur in the head

32:43

and neck or due to avena puncture and then you've got Venus malformation

32:46

which are true malformations which

32:49

are bluish and purplish. They're often superficial.

32:52

They like the head and neck and the extremities with

32:55

the trunk less common and to differentiate these

32:58

again, I remind you there's no crime in bringing

33:01

out your color flow Doppler. You've got

33:04

various syndromes that that occur with some

33:07

of these anomalies like liplanade whatever Proteus

33:10

syndrome mafuchi syndrome and Parks

33:13

wherever syndrome all beyond the scope of our

33:16

session today, but here's an AVM showing you flow void

33:19

on T2. Here's the ABM showing

33:22

you flow void on the T1 with

33:25

varying degrees of hemorrhage and in

33:28

the forearm.

33:30

Then you get into vascular masses or specialized

33:33

neoplasms these include glomus tumor

33:37

via chromocytoma and the family of ganglion

33:40

cell neoplasias, including ganglionaroma.

33:43

And sometimes they

33:46

occur in the adrenals, but often you'll find

33:49

them in the paraspinus region or in the pre-sacral region.

33:52

You've got angiosarcoma and lymphocarcoma. I

33:55

showed you already a lymphosarcoma of

33:58

a vein at the very beginning with its

34:01

high nuclear to cytoplasmic ratio

34:04

simulating a cyst on

34:07

Ultrasound with through transmission gray and

34:10

gray and then there's He Man

34:13

Joe endothelioma and Capozzi sarcoma.

34:17

Let's take one of these first the Globus tumor

34:20

Loomis tumors can occur in

34:23

the in the skull base. There's about three

34:26

different types there and in the musculoskeletal system,

34:29

they really like the pacquiaonian corpuscle

34:32

of the nail bed. Any nail bed will do

34:35

but here's the thumb you look very carefully and this

34:38

is just a normal vascular supply of

34:41

the nail bed, but not that that little nubbin.

34:44

Of hyperintensity on T2. Here's

34:47

the fat suppressed image that tiny little nubbin. They

34:50

might say well really are you going

34:53

to use Mr. To map the approach to that

34:56

lesion to splitting the nail and identifying this two millimeter

34:59

Globus tumor you bet we

35:02

are that's exactly what we're going to do. That's exactly

35:05

why you use Mr. In this scenario.

35:08

These are high water content lesions.

35:12

Just like parathyroid adenoma is a high water content

35:15

lesion. You got to know the entities. They're going

35:18

to be very very bright and here on the sagittal Stir

35:21

It is very very bright about eight

35:24

percent of them will be multiple. Here's a CT just

35:27

to keep things honest. There's a chemo dictoma

35:30

splitting the carotid arteries very

35:33

vascular but not exhibiting the speckled flow

35:36

void sign that I alluded to earlier because it

35:39

is a CT rather than an MRI. Here's a

35:42

FEA chromos cytoma, you know, they occur

35:45

in the adrenal gland, but they can occur at the organ of

35:48

Zucker candle at the aortic bifurcation and the

35:51

pre-sacral region. They tend to have intermediate to

35:54

High teach you signal not very bright, but they

35:57

often exhibit Foci of blood like this

36:00

one does on the T1 weighted image. There are

36:03

little puddles of enhancement associated with

36:06

it. And for whatever reason they will often have

36:09

this triangular shape in the

36:12

Sacral region reminiscent of an adrenal gland.

36:15

It's it's not really an adrenal gland but it's very adrenal

36:18

looking contrast that with this

36:21

lesion that I diagnosed about six months

36:24

ago. The son of a neurosurgeon he

36:27

sent me his son's case and I said, well, that's a gangliona

36:30

Roman. He said how do you know I said,

36:33

well I've seen about 50 of them over my lifetime, but I know

36:36

because it's a rising from the nurse there.

36:39

They are one two, and three and it

36:42

also demonstrates this almost perfect mnemonic

36:45

swirl sign of enhancement

36:48

internally. It's almost like it's it's a

36:51

lesion that's turning inward that combination along

36:54

with the location in the pre-sake will

36:57

region made the diagnosis and it diffusion restricted

37:00

the ganglio neuroma and in

37:03

keeping with lesions that are vascular. Here's

37:06

a lymphangioma. How do we make this diagnosis location?

37:09

It's in the neck.

37:12

It's a young person. It's pretty homogeneous. It's

37:15

very bright. So that yields

37:18

a differential diagnosis. It was not connected

37:21

to the brachial plexus in any way

37:24

so it didn't arise from it. So it's not going

37:27

to be a cystic schwannoma. It's a crazy place

37:30

for an epidermoid. So that's not a consideration. You

37:33

don't get ganglia in this location maybe

37:36

a cavernoma but not with that

37:39

shape. So after you window it down, you should come

37:42

up with a diagnosis previously known in

37:45

honor of Prince as the artist cystic High

37:48

Grandma, but it's a cystic lymphangioma.

37:52

Let's turn our attention now to desmoids you've

37:55

seen a family of fibrous lesions are ready

37:58

plant our fibromatosis. So called leader Hauser's

38:01

disease.

38:03

Um that the term desmoid means band like or tendon

38:06

like other names include muscular upon neurotic

38:09

fibromatosis or aggressive fibromatosis age

38:12

range 25 to 40. Now.

38:15

A lot of you have learned about desmoids from

38:18

surgery from cesarean section

38:21

Des Moines that occur in the abdomen perhaps

38:24

from trauma or pregnancy. They are somewhat

38:27

estrogen responsive, but

38:30

I'm also talking about extra abdominal desmoids

38:33

which may occur in the lower limb the

38:36

Lim gortal or the shoulder. Here's one in the

38:39

calf. Look at that pattern of fibrous tissue with

38:42

that musculo upon neurotic wavy hypo

38:46

intense line throughout in a

38:50

patient with a large Des Moines tumor of

38:53

the calf other fibrous mass is

38:56

include but nine fibroblastic nodular fasciitis,

38:59

which has a predilection for the forearm.

39:02

Fibroma of tendon sheath which loves the

39:05

big toe nickel fibroma, which of course

39:08

loves the neck knuckle pad fibrosis,

39:11

which likes the knuckles desmoplastic fibroma

39:14

which occurs in the ilium as

39:17

well as in the soft tissues and then the family

39:20

of fibromatosis of which you saw

39:23

a less aggressive variant the plantar fibromatosis

39:26

and then there are more aggressive variants, which

39:29

some people use as a synonym for fibrosarcoma or

39:33

fibrosarcoma light lesions many of

39:36

which like the foot. So here's an

39:39

example of one that's in the foot. Once again,

39:42

the muscular upon neurotic

39:45

wavy lines or pigeonous sign internally.

39:48

It looks a little bit like a

39:51

brain there's these there's the central

39:54

gyrus right there. There's the post Central

39:57

gyrus right there. There's a sulcus right there,

40:00

except it's in the medial.

40:02

Of the plantar fascia. It's dark

40:05

and dark like fibrous tissue is likely

40:08

to be it's in the right location. It

40:11

is large but it has the right shape. It

40:14

has the right internal character. It has the right enhancement

40:17

characteristics and it is a young to

40:20

middle-aged man it all fits together to

40:23

make the diagnosis of plantar fibromatosis

40:26

or leader Hauser's disease on the

40:29

other hand.

40:30

Here's a nondescript lesion. It is

40:33

certainly not fat. It is located in the

40:36

subcutaneous fatty area. It's

40:39

intermediate on T1 it enhances and

40:42

if you know this entity and you

40:45

look at the t2 weighted image, which I don't have

40:48

to show you it was dark. This is

40:51

a nuchal fibroma. I just couldn't resist showing

40:54

it to you.

40:55

Now, let's compare benign and malignant

40:58

lesions because that's probably one of the reasons why

41:01

you're tuning in to this MRI online courtesy

41:04

of modality lecture, you can

41:07

usually tell it is not appropriate to

41:10

say can't rule out or nonspecific. I

41:13

can't rule out life itself. I can't rule

41:16

out that there's a martian living in your body. It's a terrible expression

41:19

to use in any report and

41:22

whenever I see that I know I have a young resident

41:25

or a fellow dictating there is always some specificity

41:29

to a lesion. So I like to

41:32

have my glass half full rather than half empty. I'm

41:35

going to give a positive differential for most likely the

41:38

least likely and don't be afraid to

41:41

ask for radiographs now and again not in every case or pet

41:44

or PET CT when it's necessary, but

41:47

always give that differential from

41:50

most likely to least like so in malignancy

41:53

The Sounds of Silence, you know.

41:55

Get on the phone and you have to deliver this very nasty

41:58

message that you're dealing with something aggressive. That's

42:01

the sound of silence. There's this pregnant pause

42:04

before you start talking.

42:06

It's large. It's near the center of the body the

42:09

closer to the middle of the body. You get the worse

42:12

it is it arises from large structures.

42:15

If it's malignant, it's often very heterogeneous.

42:18

It bleeds there's a

42:21

wide zone of transition. It crosses boundaries.

42:24

It goes through the fashion. It may go into the bone. There

42:27

is rapid early Dynamic enhancement in

42:30

the first minute and it may be

42:33

associated with genetic syndromes and there may

42:36

be rapid growth. So the history can be very helpful.

42:39

Let's take a look at an example. This is

42:42

a malignant fibrous histiocytoma also

42:45

known as mixofibrosarcoma. This

42:48

one also known as the storiform pleomorphic variant

42:51

of mfh. There's

42:54

all kinds of different categorizations for this lesion, but

42:57

that's not my intent today. It's to show

43:00

you a malignant lesion that sits right on top of

43:03

bone is going to fracture this femur at

43:06

some point erode into it. It has blood inside

43:09

it and it is Uber heterogeneous like

43:12

a swirling whirling dervish of

43:15

marble inside the lesion with sidirotic

43:18

blood products. This is what a

43:21

malignant sarcoma looks like in its typical

43:24

presentation. And here it is again the

43:27

store form variant of mfh with

43:30

T1 on the left and T2 on

43:33

the right met hemoglobin staining and deoxy hemoglobin

43:36

staining and he miss sitter

43:39

in dep.

43:41

Another example of a malignancy is the

43:44

fibrosarcoma. It falls into the

43:47

family of malignant fibromyoblastic tumors,

43:50

including myxofibrosarcoma, which can sometimes

43:53

simulate assist very scary fibrosarcoma

43:56

multiforme and fibromyxoid

43:59

sarcoma. Let's deal with the fibrosarcoma. This

44:03

likes the large body parts, but it also likes the

44:06

foot as does synovial sarcoma. Here's

44:09

the C minus. Here's the C+.

44:12

Look at that very weird almost spoke

44:15

wheel like configuration of the

44:18

fibrossarcoma with peripheral enhancement and

44:21

enhancement emanating from the center of

44:24

the lesion. It looks a little bit like a choreo

44:27

carcinoma of the liver. I like in

44:30

it to that when I'm teaching this Legion and here on the

44:33

t2, it does exhibit a fibrous like low signal

44:36

intensity character with that spoke wheel

44:39

like configuration that

44:41

Described earlier on the other hand here is

44:44

a synovial sarcoma. Once again

44:47

exhibiting the characteristics of a malignant lesion.

44:50

It's large. It's very heterogeneous. It

44:53

has incredibly intense early

44:56

enhancement and it's sitting

44:59

deep right on top of the bone not yet destroying

45:02

it or eroding it. But it will these are

45:05

not tumors of synovium. They are tumors of muscle with

45:08

cells that look synovial like that

45:11

tumor likes the knee and it likes the foot and

45:14

if you're taking the core you might get asked that question.

45:18

Let's take one histology and track it and all

45:21

its glory and that is fat.

45:25

Let's go from lipoma to undifferentiated liposarcoma. And

45:28

I don't know if I'll have time to do everything in

45:31

between but maybe next time I will that is

45:34

a spectroscopic specific cell

45:37

type. It can always be identified microscopically

45:40

by doing in phase and out

45:43

of phase Imaging and looking for Signal Dropout. Like we

45:46

do in the adrenal gland or macroscopically by

45:49

MRI employing various techniques of

45:52

fat suppression. It can replace it can infiltrate

45:55

it can separate it can enhance and it can

45:58

respond to diet the more you eat the fattier you get and

46:01

to hormones.

46:03

Let's take an example of a fatty dysplasia.

46:06

This is the entity known as neurofibril lipoma

46:10

or fibrolipomatous hamartoma or

46:13

lipo fibroma of the median nerve children

46:16

and young adults men greater than women upper extremity

46:20

macrodactically and macro dystrophical lipomatosa

46:23

may occur with it and it demonstrates

46:26

the cable or spaghetti sign another another

46:29

sign for you to memorize the signal is

46:32

that of fibrous tissue dark fat, right

46:35

and neural tissue gray and

46:38

you must differentiate it from the more organized nerve sheath

46:41

lipoma. And here it is in all

46:44

its Glory with the cable or spaghetti sign.

46:47

These are actually the nerves

46:50

of the median nerve

46:53

separated by fatty tissue and associated

46:56

with an intense collection of fibrous

46:59

tissue in the middle of the enlarged dysplastic

47:02

nerve.

47:03

Fibro liponeeromatous dysplasia of

47:06

the median nerve. Here's another one. That's not a neoplasm.

47:09

This is a result of synovial metaplasia

47:12

irritation of the

47:15

synovium May produce vascular cells cartilage

47:18

ossified cartilage as

47:21

in the entity of ossified synovial chondromatosis or

47:24

this.

47:25

Lipoma arboretums of the knee an

47:28

intra-articular form of fat deposition and then

47:31

we have the lipoma.

47:34

And the liposarcoma there are several different

47:37

types of liposarcoma, but there are two that

47:40

are identifiable by MRI one

47:43

is the well-differentiated liposarcoma in

47:46

which most of it is fat with complex

47:49

septations often very large.

47:52

And the other is the myxoid tumor. So on

47:55

the left is a lipoma of the thigh almost exclusively

47:58

flat fat well-defined sharp

48:02

zone of transition fairly large,

48:05

but on the other side is

48:08

a lesion with fat that is weirdly septated and

48:11

a mixoid component. So this

48:14

is a biphasic lesion. Well differentiated liposarcoma

48:17

mixoid liposarcoma in

48:20

the same patient compared with a benign lipoma.

48:25

So I'll have you catch your breath there. We've got

48:28

a few more fatty lesions and maybe I'll just show you a few

48:31

other ones and let's

48:34

since we have a few more minutes. Let me show

48:37

you the atypical spindle cell lipoma.

48:40

How do you diagnose this a complex lipoma?

48:45

That may be associated with the clinical syndrome of pure

48:48

Red Cell. Aplasia. Myasthenia gravis and thymoma, you

48:51

gotta learn a syndrome who can memorize better than

48:54

you nobody on the planet not even Tom

48:57

Brady and memorize better than you can intramuscular

49:00

lipoma mass effect

49:03

as opposed to muscular atrophy where you

49:06

get fatty replacement of the muscle. Let's take a look at it.

49:08

On the left patient with a five Moma.

49:11

This is an example of a spindle cell lipoma. You

49:14

got to have some history to go with it. Otherwise,

49:17

you'd have to consider by bro lipomo

49:20

or he Manuel lipoma and on the right diffuse

49:23

muscular infiltration of the vastus lateralis

49:26

in an intramuscular lipoma.

49:30

And then we have LiPo blastoma. These are

49:33

associated with poorly differentiated mesenchymal cells

49:36

in a mixoid stroma. They extend

49:39

across anatomic spaces and you

49:42

can get this entity of lipoplastomatosis. This

49:45

is a pediatric condition. The lesions are

49:48

usually deep and 80% occur below

49:51

Age 3 55 percent below age

49:54

one boys greater than girls in the extremities most

49:57

are under five centimeters. They can

50:00

mature into more well-differentiated lesions,

50:03

which is really weird. They have

50:06

a higher T1 and T2 signal with scant

50:09

enhancement and remember liposarcoma is

50:12

very rare before age 10. So you see

50:15

something that's fatty and weird in the three year old think lipo

50:18

blastoma there. It is on T1 with

50:21

some fatty components and some non-fatty mesenchymal

50:24

components there. It is on T2 with

50:27

the bright signal that we alluded to

50:30

In the word slide, then there are some crazy fatty

50:33

syndromes like mad lungs

50:36

disease also known as landoab and

50:39

swad syndrome. This is associated with alcoholism frequently.

50:42

These are diabetics with hyperlipidemia hyperuricemia.

50:46

Upper Airway tumors and neuropathy. There

50:49

is an underlying mitochondrial genetic disorder not

50:52

this is not mad lungs syndrome of the forearm.

50:55

This is mad lungs disease. Look at this fatty

50:58

accumulation in the upper extremity.

51:01

You can see how this might even encroach on the airway. It

51:04

doesn't in this instance it all uniformly fat

51:07

suppresses and this patient was and an

51:10

alcoholic and I think I'll finish with

51:13

this one the hibernoma.

51:16

This was described by Merkel in 1906. This is

51:19

a tumor of brown fat. It can be

51:22

seen in neonates. Normally you'll see

51:25

brown fat and neonates and it plays a role in thermogenesis. It's

51:28

septated. It is vascular it

51:31

frequently contains some brown fat and some

51:34

standard fat. The the age range is 25 to

51:37

35 the interscapular region media

51:40

Steinem and upper thorax is common. They're painless. They're

51:43

slow growing but they may suddenly grow faster and

51:46

that's scary and they are warm and painful to

51:49

the touch. They get pretty big five to

51:52

ten centimeters in size. The enhancement is

51:55

variable. The signal is variable. The fat

51:58

suppression is variable. Everything about them

52:01

is variable. It's an interesting lesion. They

52:04

are excise similar to liposarcoma and

52:07

they are scarily hot on

52:10

pet. Where is the hibernoma the

52:13

patient complains of a mass the patient

52:16

Planes of pain here's the T1 weighted image. I don't see

52:19

much here. Maybe that right there. Maybe yes,

52:22

maybe no on the T1 weighted image, but

52:25

on the stir coronally. Oh, it's there. All

52:28

right.

52:29

Even though it looked like plain old fat. It's got

52:32

some vascularity and some zincable component

52:35

to it. There. It is enhancing on contrast

52:38

enhanced MRI with subtraction and this

52:41

is an example of the hibernoma.

52:44

Remember they are hot on pet the well

52:47

differentiated liposarc actually will be my last last

52:50

case. How do you differentiate this from

52:53

a benign lipoma and from

52:56

the family of atypical lipomaous tumors

52:59

or alts which Encompass any fatty

53:02

lesion that has atypical characteristics to

53:05

it. Well a little differentiating liposarcoma is

53:08

going to be large they'll have accepted. They

53:11

may have nodules it may not be

53:14

exclusively fat. It likes the lower extremities. It

53:17

likes to Retro peritoneum. It likes

53:20

large muscle areas. There are three subtypes lipoma

53:23

like inflammatory and sclerosing. I'm

53:26

going to show you the lipoma like one look at

53:29

Size of that thing it is huge. Could

53:32

it be a lipoma it could

53:34

but it is so gigantic with so many

53:37

bizarre septations and some nodularity at

53:40

the bottom end of it right there that you

53:43

have to at least favor. Well differentiated liposarcoma

53:46

and that it is

53:49

So with that I'll take any questions in the

53:52

chat. That was a lot of information in

53:55

a short period of time and I hope you're

53:58

still all awake.

54:00

Perfect. Thank you so much for that lecture Dr. Pomerance. We

54:03

will open the floor to questions and you can submit those via the Q&A

54:06

feature not the chat was the best way to put them

54:09

so in that Q&A feature Dr. P. If you don't mind opening that up, it looks

54:12

like we have three right now. Una is there

54:15

a difference between an aneurysm and a pseudo aneurysm on Imaging absolutely

54:18

there is

54:22

sooner aneurysms tend to clot a little

54:25

less frequently, but pseudo aneurysms are actually ruptures

54:28

of walls. So you don't have any vessel wall

54:31

or myocardial wall around a pseudo aneurysm. It

54:34

is simply covered by fibrous tissue.

54:37

So the identification of the wall aneurysm absence

54:41

of the wall pseudo aneurysm aneurysms all

54:44

tend to be concentric The Vessel comes down

54:47

and then it gets bigger and then it gets smaller. We're

54:50

pseudo aneurysm rupture to the side. They're more

54:53

eccentric. They may have a neck to

54:56

them.

54:57

Second question a large intramuscular hematoma in

55:00

the thigh without an enhancing component. Do I

55:03

represent? Do I recommend any follow-up for

55:06

concern of a possible hemorrhagic, Mass?

55:09

Well, first of all, if you have done the proper Dynamic

55:12

enhancement and you have subtracted it

55:15

and there's absolutely positively no enhancement.

55:19

Then you are dealing with a hemorrhage.

55:23

Now that being said if it's a very large lesion, I

55:26

don't think there's any harm in bringing that patient back in 9

55:29

to 12 weeks to be sure but on the other hand.

55:33

I have had innumerable patients that have come in

55:36

playing tennis playing pickleball. They come in they say

55:39

I'm in the shower. I felt my thigh. There's something big there

55:42

they come in. There's a hyperintense mass is it

55:45

fat? Is it blood and it's turned out to be a liposarc

55:48

or a mixoid liposarc. So

55:51

when in doubt

55:53

Do Dynamic contrast Imaging with subtraction not regular

55:56

contrast Dynamic contrast and then with

55:59

a delay if there's absolutely positively no enhancement.

56:02

And the lesion is modest in size you're

56:05

done as long as the lesion progressively decreases in

56:08

size and sharing that information with

56:11

clinician and patient now if it gets bigger,

56:14

They should be instructed to come back in for a follow-up.

56:17

Does your organization use Dixon sequence and soft

56:20

tissue Imaging we do use Dixon sequence Imaging and

56:23

soft tissue evaluation. So the answer to that

56:26

question is yes, how do you evaluate the treatment changes

56:29

of fibro fibromatosis size and

56:32

Signal changes?

56:34

Well first doctors saying

56:37

fibromatosis is a very difficult lesion to deal with even leaderhausers

56:40

disease in the foot. We

56:43

try not to resect these unless they're

56:46

really large and if they are really large, then

56:49

you have to have that very broad margin and it

56:52

can be a very deforming surgery.

56:55

The best way to see how your resection

56:58

has done is actually not contrast enhanced

57:01

Mr. Because you get a fair amount of granulation tissue.

57:04

It's having a baseline after surgery, which

57:07

you should do.

57:09

In a resection of a large fibromatosis lesion and

57:12

then surely following those fibrous signals

57:15

over a period of time at six nine 12

57:18

and 24 months to see if everything is

57:21

peachy and stable. How do you differentiate between

57:24

a hematoma and a soft tissue tumor on a

57:27

non-enhanced mlri study?

57:30

That's a good question. I think

57:33

you have to use every single tool that that's

57:36

available to you, and if you're in doubt get a

57:39

nine week follow-up, but what are those

57:42

tools that are available to you Dynamic contrast enhanced

57:45

Imaging. Is it in a place where you'd expect a tumor to

57:48

be does it have fat in it. Does it have fibrous tissue

57:51

in it? Does it have one of those signals or signs that

57:54

I alluded to earlier? So you have to take the entire

57:57

compilation of your education your

58:00

experience and your visual library to weigh

58:03

in and if you're in doubt do that nine week

58:06

follow up. What delay do you use on

58:09

your Dynamic post contrast sequences three to

58:12

five minutes is plenty of the leg. No question.

58:15

Just many. Thanks. Thank you from my

58:18

friends and us

58:20

With that, I think we've exhausted all our Q&A

58:23

questions. I really appreciate

58:26

you up. There's one more quick question. Is there

58:29

a small if there is a small intramuscular

58:32

lipoma?

58:34

Is it'll leave me alone lesion or do you like to follow it up?

58:37

If it is fat if it is

58:40

not septated if it has no nodules, I do

58:43

not follow those up. I do measure them and I

58:46

let the clinician know that it's a lipoma. So when they see the patient

58:49

again, they can have a look at it, but I do not follow those

58:52

up because lipomas are incredibly common and

58:55

you will be doing MRIs on all your

58:58

friends all your family and all your patients and while that's

59:01

good for business. It's not good for the patients with that.

59:04

I will say thank you to my colleagues

59:07

at MRI online and thank you to my colleagues

59:10

at its parent company modality. Have a

59:13

great day.

59:14

Perfect. Thank you so much for that lecture today Dr. Pomeranians, and

59:17

thank you to all of you for participating in our new conference. You can

59:20

access the recording of today's conference and all previous noon

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