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Characterization of Musculoskeletal Lesions on 3-T Proton MR Spectroscopy

Laura M. Fayad1, Peter B. Barker2, Michael A. Jacobs3, John Eng4, Kristin L. Weber5, Piotr Kulesza6 and David A. Bluemke7

1 Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine and Johns Hopkins Medical Institutions, 601 N Caroline St., JHOC 3171C, Baltimore, MD 21287.
2 Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD.
3 Division of MR Research, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD.
4 Department of Radiology, Health Science Informatics, Johns Hopkins University School of Medicine, Baltimore, MD.
5 Division of Orthopaedics and Oncology, Department of Orthopaedic Surgery, Johns Hopkins Medical Institutions, Baltimore, MD.
6 Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD.
7 MRI Division, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD.


Figure 1
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  		Fig. 1 —58-year-old man with palpable right thigh softtissue mass in whom imaging-guided percutaneous biopsy with needle aspiration and core biopsies revealed myofibroblastic lesion of uncertain malignant potential, possibly representing fibromatosis, schwannoma, or low-grade sarcoma (although low-grade sarcoma was favored by histology). MRI and MR spectroscopy of right thigh mass are shown, with MR spectroscopy results highly favoring malignancy. Final pathology (Figs. 1F, 1G, 1H, 1I) after resection showed low-grade sarcoma.

A, Coronal inversion recovery STIR image (TR/TE, 2,462/100; inversion time, 200 milliseconds) of right thigh shows ovoid heterogeneous mass.

B, Coronal spin-echo T1-weighted image (690/15) of right thigh shows same mass for comparison.

C, Axial gradient-recalled echo contrast-enhanced T1-weighted image (8.7/4.3; flip angle, 90°) shows that mass enhances after contrast administration.

D, Axial fast spin-echo T2-weighted image (2,886/100) shows mass with placement of 2 x 2 x 2 mL voxel over lesion.

E, Corresponding single-voxel point-resolved spectroscopy MR spectroscopy (2,000/144) shows discrete choline (Cho) peak in lesion, with choline signal-to-noise ratio of 18.6, indicating malignancy.

 

Figure 2
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  		Fig. 1F —58-year-old man with palpable right thigh soft-tissue mass in whom imaging-guided percutaneous biopsy with needle aspiration and core biopsies revealed myofibroblastic lesion of uncertain malignant potential, possibly representing fibromatosis, schwannoma, or low-grade sarcoma (although low-grade sarcoma was favored by histology). MRI and MR spectroscopy of right thigh mass are shown, with MR spectroscopy results highly favoring malignancy. Final pathology (Figs. 1F, 1G, 1H, 1I) after resection showed low-grade sarcoma. Histology of core biopsy of lesion shows histologic appearance is moderately cellular, with spindle cells arranged in fascicles. (H and E, x200)

 

Figure 3
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  		Fig. 1G —58-year-old man with palpable right thigh soft-tissue mass in whom imaging-guided percutaneous biopsy with needle aspiration and core biopsies revealed myofibroblastic lesion of uncertain malignant potential, possibly representing fibromatosis, schwannoma, or low-grade sarcoma (although low-grade sarcoma was favored by histology). MRI and MR spectroscopy of right thigh mass are shown, with MR spectroscopy results highly favoring malignancy. Final pathology (Figs. 1F, 1G, 1H, 1I) after resection showed low-grade sarcoma. Histology of core biopsy of lesion shows lesional cells are positive for smooth muscle actin, which supports myofibroblastic differentiation. (Immunoperoxidase, x400)

 

Figure 4
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  		Fig. 1H —58-year-old man with palpable right thigh soft-tissue mass in whom imaging-guided percutaneous biopsy with needle aspiration and core biopsies revealed myofibroblastic lesion of uncertain malignant potential, possibly representing fibromatosis, schwannoma, or low-grade sarcoma (although low-grade sarcoma was favored by histology). MRI and MR spectroscopy of right thigh mass are shown, with MR spectroscopy results highly favoring malignancy. Final pathology (Figs. 1F, 1G, 1H, 1I) after resection showed low-grade sarcoma. Histology of final resection specimen. Sarcoma (grade I–III) shows similar features to those seen on core biopsy, with prominent chronic inflammatory component. (H and E, x100)

 

Figure 5
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  		Fig. 1I —58-year-old man with palpable right thigh soft-tissue mass in whom imaging-guided percutaneous biopsy with needle aspiration and core biopsies revealed myofibroblastic lesion of uncertain malignant potential, possibly representing fibromatosis, schwannoma, or low-grade sarcoma (although low-grade sarcoma was favored by histology). MRI and MR spectroscopy of right thigh mass are shown, with MR spectroscopy results highly favoring malignancy. Final pathology (Figs. 1F, 1G, 1H, 1I) after resection showed low-grade sarcoma. Histology of final resection specimen shows higher power view of focal myxoid area, which is consistent with low-grade histology. (H and E, x200)

 

Figure 6
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  		Fig. 2 —51-year-old man with resected low-grade myxofibrosarcoma and postsurgical myocutaneous flap of right lower extremity.

A, Axial spin-echo T1-weighted image (TR/TE, 660/15) shows myocutaneous flap with voxel placement.

B. MR spectroscopy in flap shows typical spectrum of muscle, creatine peak higher than choline peak, as well as water and lipids.

 

Figure 7
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  		Fig. 3 —3-year-old boy with unicameral bone cyst of right humerus proven by aspiration, steroid injection, and follow-up until resolution of symptoms.

A, Axial fast spin-echo T2-weighted image (TR/TE, 2,886/100) shows fluid–fluid levels in partially cystic lesion with solid components. Voxel was placed over solid portion of lesion.

B, Single-voxel MR spectroscopy obtained in solid portion shows only large water peak, consistent with history of healing cyst.

 

Figure 8
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  		Fig. 4 —45-year-old man with lipoma of left forearm that was resected and proven histologically. A, Axial fat-suppressed spin-echo T1-weighted (TR/TE, 650/15) image obtained after contrast administration shows internal enhancement of septations in mass, a nonspecific finding that can occasionally be seen with well-differentiated liposarcoma. Voxel was placed over area of abnormal signal. Note that this image was obtained on different day from day on which MR spectroscopy was performed because all MR spectroscopy imaging was obtained before contrast administration in this series. B, Single-voxel MR spectroscopy image obtained in area of abnormal signal shows large lipid peak, confirming lipomatous nature of mass, with no detectable choline to suggest malignancy.

 

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