《树枝状脂肪瘤.ppt》由会员分享，可在线阅读，更多相关《树枝状脂肪瘤.ppt（38页珍藏版）》请在三一文库上搜索。
1、2012年9月11日：遵义,遵义市第一人民医院影像科,Lipoma Arborescens 树枝状脂肪瘤,* 遵义市第一人民医院影像科 袁西伟,2012年9月11日：遵义,遵义市第一人民医院影像科,男性 38岁，膝关节及大腿中下部肿胀疼痛2年余，加重1天，查体：肿胀、压痛。膝关节有手术史。建议患者住院治疗，因经济困难不能住院。,2012年9月11日：遵义,遵义市第一人民医院影像科,2012年9月11日：遵义,遵义市第一人民医院影像科,2012年9月11日：遵义,遵义市第一人民医院影像科,STOUT, A. P.: Atlas of Tumor Pathology. Section II, Fa
2、scicle 5. Tumors of Soft Tissue. Vaslmington, Anmenican Registry of Pathology, Armed Forces Institute of Pathology, 1953. Napolitano A. Lipoma arborescens of the synovial uid: clinical contribution to a case located at the synovia of the wrist. Progresso Medico 1957;13:109-18. Arzimanoglu A: Bilater
3、al arborescens lipoma of the knee.J Bone Joint Surg Am 39:976, 1957 Hallel T, Lew S, Bansal M. Villous lipomatous proliferation of the synovial membrane (lipoma arborescens). J Bone Joint Surg Am1988; 70:264270.,First Reported and Earlier Reported,2012年9月11日：遵义,遵义市第一人民医院影像科,【病因】The etiology of lipom
4、a arborescens is unknown. It has been associated with rheumatoid arthritis, osteoarthritis, and joint injuries. It has previously been described with degenerative joint disease and chronic rheumatoid arthritis.,Etiology,2012年9月11日：遵义,遵义市第一人民医院影像科,J Radiol Case Rep. 2011; 5(11): 1725. Published onlin
5、e 2011 November 1. doi: 10.3941/jrcr.v5i11.783PMCID: PMC3303421 Lipoma Arborescens of Knee Joint: Role of Imaging,A 23 year old Asian female presented with swelling of right knee joint for 5 years,2012年9月11日：遵义,遵义市第一人民医院影像科,2012年9月11日：遵义,遵义市第一人民医院影像科,Lipoma arborescens of the elbow,A 22-year-old mal
6、e with complaints of gradual swelling of the left elbow for 3 years and pain for 1 year. He had no past history of trauma or other joint problems.,2012年9月11日：遵义,遵义市第一人民医院影像科,An 80-year-old male patient,Lipoma arborescens of the subdeltoid bursa: a case report,2012年9月11日：遵义,遵义市第一人民医院影像科,CLINICAL PRES
7、ENTATION: Patient is a 41-year-old male with chronic painless knee swelling. IMAGING FINDINGS: There is a large knee joint effusion. Frond-like synovial projections are evident. These follow fat signal on all sequences.,Figure 1: PD weighted coronal MR image of the knee. There is a large joint effus
8、ion. High signal ovoid synovial projections are seen (arrow). Figure 2. Fat saturated T2 coronal MR image of the knee. There is a large joint effusion (*). The synovial projections have very low signal on this fat saturated sequence. Observe that the signal pattern of the synovial projections follow
9、s that of fat (bone marrow) on all sequences.,2012年9月11日：遵义,遵义市第一人民医院影像科,2012年9月11日：遵义,遵义市第一人民医院影像科,The first patient was a 75-year-old woman who had a 6-year history of painless left ankle swelling that became painful 1 week previously. The other patient was a 17-year-old boy with a 1-year history
10、of progressive right knee swelling and a limited range of movement. The boy had a 12-year history of psoriasis.,2012年9月11日：遵义,遵义市第一人民医院影像科,Figure . A, Sagittal oblique multiplanar reformation showing fat density (arrows) within prominent effusion on the anterolateral aspect of the left ankle. B, Tra
11、nsverse CT showing fat density (arrows) in prominent effusion around the extensor digitorum longus tendon.,2012年9月11日：遵义,遵义市第一人民医院影像科,Figure . A, Sagittal proton densityweighted image showing hyperintense projections (arrows) in prominent effusion in the suprapatellar pouch. B, Sagittal fat-saturate
12、d T1-weighted image showing the fatty nature of the projections (arrows), which are suppressed with a fat suppression technique.,2012年9月11日：遵义,遵义市第一人民医院影像科,Figure . A, Transverse sonogram of the left ankle showing villous and frondlike hyperechoic projections (arrows) in prominent effusion around th
13、e extensor digitorum longus tendon. B, Transverse sonogram of the suprapatellar pouch showing homogeneous hyperechoic villous and globular projections (arrows) within prominent effusion.,2012年9月11日：遵义,遵义市第一人民医院影像科,Figure . A, Color Doppler sonogram showing minimal vascularization. On spectral analys
14、is, a low-resistance flow pattern is shown.B, Color Doppler sonogram showing minimal to moderate vascularization of the projections. On spectral analysis, a low-resistance flow pattern is shown.,2012年9月11日：遵义,遵义市第一人民医院影像科,Figure . A, Photomicrograph of the surgically removed specimen showing synovia
15、l villous proliferations with hyperplasia of mature fat cells (F), congested hyperemic capillaries (black arrows), and chronic inflammatory cells (white arrow) within the subsynovial tissue (hematoxylin-eosin, original magnification 100). B, Photomicrograph of the surgically removed specimen showing
16、 hyperplasia of mature fat cells of the subsynovial tissue, congested hyperemic capillaries (black arrows), and chronic inflammatory cells. The synovial lining is also shown (white arrow) (hematoxylin-eosin, original magnification 100).,2012年9月11日：遵义,遵义市第一人民医院影像科,Figure 1 Patient was a 74 year old w
17、oman with lipoma arborescens of the suprapatellar bursa, manifested as a swelling and mass. A, Transverse sonogram demonstrates globular and villous hyperechoic structures projecting into the suprapatellar effusion. Arrows indicate the femur. B, Axial T1-weighted MR image demonstrates villous struct
18、ure with fatty signal in the suprapatellar bursa deep to the skin marker placed where the patient reported the mass.,2012年9月11日：遵义,遵义市第一人民医院影像科,Figure 2 Patient was 70 year old woman with lipoma arborescens of the suprapatellar bursa. This lesion had a more pointed, jagged appearance. Arrows indicat
19、e the femur.,2012年9月11日：遵义,遵义市第一人民医院影像科,Figure 1. Lipoma arborescens of the elbow in a 62-year-old woman. A, Longitudinal sonogram showing a multilobulated hyperechoic mass (asterisks), partly surrounded by fluid, located between the biceps tendon and the radial head (RH) and radial neck (RN). A sha
20、rp enthesophyte (arrowhead) was identified at the radial tuberosity (RT). B, Horizontal sonogram showing the mass (asterisks) closely applied to the brachialis muscle (Br) and wrapping around the distal biceps tendon (Bi) toward its insertion on the radius.,2012年9月11日：遵义,遵义市第一人民医院影像科,C, Horizontal T
21、1-weighted spin echo magnetic resonance image showing a multilobulated mass (asterisk) with mixed fatty and soft tissue signals surrounded by fluid. A sharp enthesophyte is shown at the radial tuberosity (arrowhead). D, Anterior surgical view showing a large cystic mass (black arrowheads) that envel
22、ops the distal biceps tendon and a radial tuberosity enthesophyte (white arrowhead). CR indicates cranial.,2012年9月11日：遵义,遵义市第一人民医院影像科,A 41-year-old male aircraft engineer presented with a 6 year history of a painful, stiff dominant wrist since sustaining a non-displaced scaphoid fracture, with a mor
23、e recent onset of a dorsal swelling of the hand.,2012年9月11日：遵义,遵义市第一人民医院影像科,2012年9月11日：遵义,遵义市第一人民医院影像科,2012年9月11日：遵义,遵义市第一人民医院影像科,Summary table for lipoma arborescens Incidence Rare (Uncommon), around hundred reported cases Gender ratio Equal Predominance in both sexes Age 9 to 68 years Risk factors
24、 Unknown, but is associated with degenerative joint diseases, trauma, meniscal injuries, chronic synovitis or arthritis. Treatment Synovectomy Prognosis Good (Recurrence is rare) Imaging Findings X-Ray Fullness of suprapatellar pouch due to a soft tissue mass like lesion in the suprapatellar region
25、with sometimes associated with scattered lucent areas. Ultrasound Frond like villous projections of the synovium associated with Joint effusion. MRI Frond like thickening of the synovium appears hyperintense on T1 and T2 similar to fat with suppression of signals from fronds on fat saturated sequenc
26、es associated with joint effusion.,2012年9月11日：遵义,遵义市第一人民医院影像科,DISCUSSION,LA is an uncommon intra-articular lesion consisting of villous lipomatous proliferation of the synovium seen in the knee joint, usually in the suprapatellar pouch. This condition is also seen in the glenohumeral joint, hip join
27、t, elbow joint and subdeltoid bursa 1. Less than hundred cases have been reported2.,2012年9月11日：遵义,遵义市第一人民医院影像科,LA is a benign lesion arising from the synovium. It is characterized by villous proliferation of fat cells. The proliferating cells appear organic and resemble a tree, thus the name arbores
28、cens, from the Latin word arbor for tree. The exact cause is not known. One explanation is that the synovial hyper-proliferation occurs in response to trauma and inflammation. LA is usually associated with trauma, osteoarthritis and rheumatoid arthritis but there have also been cases without any und
29、erlying cause3.,2012年9月11日：遵义,遵义市第一人民医院影像科,There are 2 types of LA - primary and secondary. The primary type is usually not associated with degeneration of the knee joint. The secondary type is more common than the primary type and is defined as lipomatosis associated with chronic irritation. LA is
30、a reactive process of the synovium due to chronic irritation, seen in conditions like degenerative joint diseases, trauma, meniscal injuries, chronic synovitis or arthritis, but it is not a true neoplasm4. Lipoma arborescens is noted between the age group of 9 to 68 years with an equal predominance
31、both in women and men5.,2012年9月11日：遵义,遵义市第一人民医院影像科,Patients present with chronic painless swelling of the knee of several years duration. The lesions are non tender and soft in consistency. Patients usually do not have history of trauma but their symptoms are cyclical with intermittent exacerbation
32、caused due to trapping of the lipoma villi in the joint space 4. Laboratory tests like ESR and serologic studies for rheumatoid factor and uric acid levels are normal. Joint aspirate is usually negative for crystals and cells. Culture for joint fluid is also negative 1.,2012年9月11日：遵义,遵义市第一人民医院影像科,Ou
33、r patient was a 23 year old female who presented with painless swelling of the knee joint for five years with exacerbations and remissions. There was no under lying cause. The swelling was soft on palpation and non tender. Her lab tests which included complete analysis of blood, synovial fluid and s
34、erology were all negative.,2012年9月11日：遵义,遵义市第一人民医院影像科,Diagnosis - Role of imaging Radiographs show a soft tissue lesion in the suprapatellar pouch often associated with osteoarthritic changes 6. Ultrasound reveals frond-like projections of the mass which move in real time with an associated joint ef
35、fusion 3. X-ray -AP and lateral views of the right knee joint, in this case, showed fullness of the suprapatellar pouch due to a soft tissue mass like lesion in the suprapatellar region. There were no signs of osteoarthritis and the bones appeared normal. Ultrasonography revealed frond like villous
36、projections of the synovium with an associated joint effusion. Magnetic resonance imaging is the gold standard investigation to diagnose lipoma arborescens 4. It produces high contrast multiplanar images which depict deep cortical bone, marrow, ligaments, tendons, fat, menisci and articular cartilag
37、e in one image. In addition to these, it is non-invasive without the use of ionizing radiation 5.,2012年9月11日：遵义,遵义市第一人民医院影像科,The MRI imaging findings are pathognomic for LA. The findings include 1) A synovial mass with a frond like architecture 2) Fat signal intensity on all pulse sequences 3) Suppr
38、ession of signal with fat-selective presaturation 4) Associated joint effusion 5) Potential chemical shift artifact 6) Absence of magnetic susceptibility effects from hemosiderin 6. The discussed case showed frond like villous projections in suprapatellar region, with joint effusion having signal in
39、tensity of fat on all pulse sequences , with corresponding suppression on fat-suppressed proton density sequence.,2012年9月11日：遵义,遵义市第一人民医院影像科,Differential diagnosis,Lipoma arborescens Pigmented villonodular synovitis Synovial osteochondromatosis Synovial hemangioma Rheumatoid arthritis,2012年9月11日：遵义,
40、遵义市第一人民医院影像科,Differential diagnosis MRI reveals findings that are characteristic of lipoma arborescens, but there are some conditions which may mimic lipoma arborescens clinically and sometimes pose a dilemma even radiologically. Appearance of the lesion and its signal intensity changes on various p
41、ulse sequences, combined with associated findings help in differentiating it from other conditions. Some of the conditions are as follows : Synovial lipoma Intra-articular synovial lipoma appears as a small, single, polyp like mass, round to oval in shape, with a short stalk arising from the fat pad
42、 area of the suprapatellar pouch, either penetrating the synovial membrane or as a result of fat over growth within the intra- articular synovial tissue, whereas lipoma arborescens appears as a frond like mass 4. Absence of subsynovial fat deposition, villous appearance of the lesion, joint effusion
43、 and synovial cyst formation help in differentiating it from LA 7.,2012年9月11日：遵义,遵义市第一人民医院影像科,Pigmented villo nodular synovitis (PVNS) MRI is the investigation of choice as hemosiderin deposition leads to signal loss on both T1 and T2 weighted sequences and gradient echo sequences 8. PVNS reveals a
44、lobulated mass with reduced signal intensity on T1 and T2 weighted images due to hemosiderin. Surrounding effusion and areas of fat within the lesion may also be noted in this condition 3. Synovial Chondromatosis This condition is associated with effusion and adjacent erosions. The signal intensity
45、of intra articular bodies varies depending on the amount of cartilage or bones present 3. Synovial Hemangioma This lesion appears as an intra-articular mass lobulated in nature showing intermediate signal intensity on T1 weighted sequences and appears more hyperintense than subcutaneous fat on T2 an
46、d fat saturated sequences. There are some areas of low signal intensity, supposedly representing fibrous septa. Further these lesions also show enhancement on post gadolinium study 3. Rheumatoid arthritis The pannus appears as intermediate to low signal intensity on T1 and T2 weighted images. Other
47、findings -like joint space narrowing, erosions and intraarticular loose (rice) bodies may also be seen 3.,2012年9月11日：遵义,遵义市第一人民医院影像科,Treatment and Prognosis Arthrotomy and synovectomy is usually recommended in LA. The lesion is accessible through arthroscopic ports. Arthroscopy is the method of choi
48、ce as it reduces soft tissue trauma and speeds up postoperative rehabilitation. Recurrence of LA is rare 4. TEACHING POINT Lipoma Arborescens (LA) is a rare intra-articular benign lesion seen most often in the knee joint. It should be considered in the differential diagnosis of painless swelling of
49、the joint. MRI is the imaging modality of choice as it depicts the characteristic findings like 1) Synovial mass with a frond like architecture 2) Fat signal intensity on all pulse sequences 3) Suppression of signal with fat-selective presaturation 4) Associated joint effusion which are pertinent to LA and allows for a specific preoperative diagnosis.,2012年9月11日：遵义,遵义市第一人民医院影像科,Thank you,