Figure 1
Fig 1
Figure 1. Ultrasonographic study, medial sagittal plane. Mixed mass, with a cystic component and a hyperechogenic, fatty, component.
Woman with a painful mass in the ulnar fossa of the right elbow (ECR 2005 Case of the Day)
SectionMusculoskeletal system
Case TypeClinical Cases
Authors
Ros Mendoza L1, Mayayo Sinués E1, Marín Cárdenas MA1, Azúa RomeoJ2, De la Cueva Barrao L3.
Deparment of 1) Radiology, 2) Pathology* and 3) Nuclear Medicine, University Hospital Miguel Servet, Zaragoza, Spain.
Connected authors
56 years, female
Clinical History
We present the case of a 56 year old woman with a painful mass located in the anterior ulnar fossa of the right elbow with slow growing and 6 months evolution.
There were no traumatic antecedents, nor systemic disease or another joint involvement.
There were no traumatic antecedents, nor systemic disease or another joint involvement.
Imaging Findings
Figure 1: US study, medial sagittal plane. Mixed mass, with a cystic component and a hyperechogenic, fatty, component.
Figure 2: Axial FSE T1 MR image. Mass located between the bicipital tendon and the radius, with a mixed signal, and hyperintense areas corresponding to fatty tissue proliferations.
Figure 3: Sagittal FSE T2, fat suppressed, MR. Mass with a hyperintense fluid component, inner formations of low signal intensity related to fat suppression.
Figure 4: Axial GRE T2* MR. Fluid collection with areas of low signal intensity.
Figure 5: Axial FSE T1, fat suppressed, MR after intravenous contrast administration. Increase of signal intensity of the mass related to synovitis.
Figure 6: Isotopic scan. Increase of vascularity of the radial border of the right forearm in the vascular phase (*) and a slight increase of intake in the osseous phase (→).
Figure 7: Microscopic correlation. Subsynovial proliferations, presence of mature adipocytes (*), chronic inflammatory infiltrates and vascular congestion.
Figure 2: Axial FSE T1 MR image. Mass located between the bicipital tendon and the radius, with a mixed signal, and hyperintense areas corresponding to fatty tissue proliferations.
Figure 3: Sagittal FSE T2, fat suppressed, MR. Mass with a hyperintense fluid component, inner formations of low signal intensity related to fat suppression.
Figure 4: Axial GRE T2* MR. Fluid collection with areas of low signal intensity.
Figure 5: Axial FSE T1, fat suppressed, MR after intravenous contrast administration. Increase of signal intensity of the mass related to synovitis.
Figure 6: Isotopic scan. Increase of vascularity of the radial border of the right forearm in the vascular phase (*) and a slight increase of intake in the osseous phase (→).
Figure 7: Microscopic correlation. Subsynovial proliferations, presence of mature adipocytes (*), chronic inflammatory infiltrates and vascular congestion.
Discussion
Lipoma arborescens (LA) is a synovial entity that consists of a hyperplastic proliferation of fatty tissue that replaces the subsynovial connective layer, under the form of villous proliferations. It is usually a monoarticular disorder mainly located in the knee with a unilateral form of presentation, which tends to involve the suprapatelar recess and clinically characterized by progressive chronic synovial discharge and painful exacerbations.
The bicipitoradial bursa location of LA is very rare. There are only five previous cases described in the scientific literature. Although some of the LA cases in other different locations from the elbow are related to osteoarthritis or inflammatory arthropathy, in the bicipitoradial location the aetiology is unknown. The chronic synovial inflammation is thought to have a probable traumatic origin, secondary to a repeated friction of the bursa related to the forced pronation of the forearm.
Conventional radiology and CT can show the fatty density of this tumour, but MR is the imaging modality that allows a correct diagnosis of LA, as in our case, when a mass with fatty deposits and a frond-like appearance is identified.
Most cases present a good response to the intraarticular steroid administration, which is used to control the exacerbations, but the most common treatment is the arthroscopic or open synovectomy, as in the case we are dealing with.
The bicipitoradial bursa location of LA is very rare. There are only five previous cases described in the scientific literature. Although some of the LA cases in other different locations from the elbow are related to osteoarthritis or inflammatory arthropathy, in the bicipitoradial location the aetiology is unknown. The chronic synovial inflammation is thought to have a probable traumatic origin, secondary to a repeated friction of the bursa related to the forced pronation of the forearm.
Conventional radiology and CT can show the fatty density of this tumour, but MR is the imaging modality that allows a correct diagnosis of LA, as in our case, when a mass with fatty deposits and a frond-like appearance is identified.
Most cases present a good response to the intraarticular steroid administration, which is used to control the exacerbations, but the most common treatment is the arthroscopic or open synovectomy, as in the case we are dealing with.
Differential Diagnosis List
Lipoma arborescens of the elbow bicipital bursa
Synovial osteochrondromatosis
Synovial lipoma
Liposarcoma
Hemangioma
Final Diagnosis
Lipoma arborescens of the elbow bicipital bursa
References
[1] Sola JB, Wright RW (1998) Arthroscopic treatment for lipoma arborescens of the knee. J Bone Joint Surg 80(1):99-103 (PMID: 9469315)
[2] Martín S, Hernández L, Romero J, Lafuente J, Poza AI, Ruiz P, Jimeno M (1998) Diagnostic imaging of lipoma arborecescens. Skeletal Radiol 27: 325-329 (PMID: 9677649)
[3] Doyle AJ, Miller MV, French JG (2002) Lipoma arborescens in the bicipital bursa of the elbow: MRI findings in two cases. Skeletal Radiol 31: 656-660 (PMID: 12395278)
[4] Levadoux M, Gadea J, Flandrin P, Carlos E, Aswad R, Panuel M (2000) Lipoma arborescens of the elbow: a case report. J Hand Surg 25: 580-584 (PMID: 10811766)
[5] Chaljub G, Johnson PR (1996) In vivo MRI characteristics of lipoma arborescens utilizing fat suppression and contrast administration. J Comput Assist Tomogr 20: 85-87 (PMID: 8576487)
Case information
| URL: | https://www.eurorad.org/case/8980 |
| DOI: | 10.1594/EURORAD/CASE.8980 |
| ISSN: | 1563-4086 |
Figure 2
Fig 2
Figure 2. Axial FSE T1 MR image. Mass located between the bicipital tendon and the radius, with a mixed signal, and hyperintense areas corresponding to fatty tissue proliferations.
Figure 3
Fig 3
Figure 3. Sagittal FSE T2, fat suppressed, MR. Mass with a hyperintense fluid component, inner formations of low signal intensity related to fat suppression.
Figure 4
Fig 4
Figure 4. Axial GRE T2* MR. Fluid collection with areas of low signal intensity.
Figure 5
Fig 5
Figure 5. Axial FSE T1, fat suppressed, MR after intravenous contrast administration. Increase of signal intensity of the mass related to sinovitis.
Figure 6
Fig 6
Figure 6. Isotopic scan. Increase of vascularity of the radial border of the right forearm in the vascular phase (*) and a slight increase of intake in the osseous phase (→).
Figure 7
Fig 7
Figure 7. Microscopic correlation. Subsinovial proliferations, presence of mature adipocytes (*), chronic inflammatory infiltrates and vascular congestion.
Fig 1
Figure 1. Ultrasonographic study, medial sagittal plane. Mixed mass, with a cystic component and a hyperechogenic, fatty, component.
Fig 2
Figure 2. Axial FSE T1 MR image. Mass located between the bicipital tendon and the radius, with a mixed signal, and hyperintense areas corresponding to fatty tissue proliferations.
Fig 3
Figure 3. Sagittal FSE T2, fat suppressed, MR. Mass with a hyperintense fluid component, inner formations of low signal intensity related to fat suppression.
Fig 4
Figure 4. Axial GRE T2* MR. Fluid collection with areas of low signal intensity.
Fig 5
Figure 5. Axial FSE T1, fat suppressed, MR after intravenous contrast administration. Increase of signal intensity of the mass related to sinovitis.
Fig 6
Figure 6. Isotopic scan. Increase of vascularity of the radial border of the right forearm in the vascular phase (*) and a slight increase of intake in the osseous phase (→).
Fig 7
Figure 7. Microscopic correlation. Subsinovial proliferations, presence of mature adipocytes (*), chronic inflammatory infiltrates and vascular congestion.