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Aspiration option for symptomatic palpable mass

Discussion in 'General Issues and Discussion Forum' started by Saab, Jul 20, 2010.

  1. Saab

    Saab Member


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    Hi Everyone I was wondering if I could get your thoughts on a patient of mine..

    History
    24 year old male

    Healthy.. no underlying health issues

    has a palpable mass on the medial aspect of the first MTPJ present for 4 -5 years

    no history of trauma

    sensitive when objects brush against it not so much when applied with perpendicular pressure

    Footwear is unremarkable.. not tight at lesion site

    doesn't participate in regular sporting activities

    sent for Ultrasound which showed:

    a heterogeneous thickening of the subcutaneous tissue that is mainly hypo echoic. the area is not vascular.
    measures approx 1.0 x0.36 x 1.9cm in dimensions
    no evidence of joint effusion

    My thoughts are
    1) since being mainly fluid, it should be aspirational ?( new word Palin style) lol
    2) since the area is not vascular it would be potentially clean without blood and with potentially less pain?
    3) would it be reasonable to burst the lesion and let the contents be absorbed by surrounding tissue?
    4) or would it be a better idea to try and decrease size of the lesion by aspirating as much fluid as possible? guage size?

    he is interested in trying something to treat the lesion

    Hope i haven't missed anything

    Steve
     
  2. Mart

    Mart Well-Known Member

    Hi Steve

    Since the lesion is heterogeneous it is unlkley to be a simple bursa or cystic mass.

    By non vasular probably means that there was no measurable
    signal with power doppler imaging, it may contain blood laden tissue, however, if so , it is just not moving sufficiently to detect motion of RBCs with US. For example hypertrophic joint synovial tissue may have no signal with power doppler imaging but aspirate blood when not inflamed.

    Is there joint deformity? from location sounds like possible adventitious bursa which may be contain some debris, could you post US images and or photos for us to see?

    What would be reason for intervention?


    cheers

    Martin


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  3. Saab

    Saab Member

    Thanks for the info Martin.

    Ive tried to get the Imaging to send me digital copies of the images but they don't offer it for US and Xray.
    When i scan the Xray its way too large to post. Ill ask my brother the computer genius if he has any ideas.

    The reason for intervention is that is can randomly cause hypersensitivity especially in snow boots/football boots or when something brushes against it and he is sick of having to worry about it.
    He is very interested in trying to treat it so i suggested bursting or aspirating it.

    there is no obvious mal-alignment of the MPJ or bony deformity shown on Xray.

    Ill work on getting some photos

    cheers
     
  4. Mart

    Mart Well-Known Member


    I do a quite a bit of high res US imaging of soft tissue masses in foot and and am always very cautious about interpretation of masses which are not clearly simple cysts or bursas because although rare, in patients aged 6-45 years, synovial sarcoma is the most common sarcoma in the foot and ankle. Most synovial sarcomas are found within 5 cm of a joint. Despite the misnomer, only 10% of cases are intra-articular. The tumors are usually well circumscribed, but in unusual cases, they may interdigitate between muscles and tendons or encase neurovascular structures.

    There is some element of suspicion for your pt based on hx; slow growing, no obvious mechanical cause, some pain which is not clearly understood.

    Your sonographic Findings;
    Ultrasonography does not play a significant role in the evaluation of synovial sarcomas. The imaging characteristics cannot be used to establish a precise diagnosis. Grossly, sonograms can provide information regarding the size and consistency of a soft-tissue mass (eg, differentiating cystic from solid masses or a localized mass from diffuse edema). Most commonly, a well-circumscribed, heterogeneous mass, with or without cystic components, is seen.
    Ultrasonography can be useful as a real-time imaging technique for guiding diagnostic needle biopsy, especially in large heterogeneous tumors.19 Color-flow Doppler ultrasound imaging reveals blood flow in solid soft-tissue masses.19
    Degree of Confidence

    Studies have shown that color-flow Doppler ultrasound findings are not specific for differentiating benign from malignant tumors; however, the technique may be useful for monitoring the regression of tumor neovascularity after the administration of chemotherapy or irradiation.

    Synovial sarcoma tumors can appear small, especially those in the hands or head and neck regions,2,13,16 where they come to medical attention earlier. Often, the small size, well-defined margins, and sometimes homogeneous appearance of synovial sarcoma can lead to misdiagnosis as a benign lesion. Berquist et al found that synovial sarcoma was the malignant soft-tissue sarcoma most frequently misdiagnosed as benign.17 Small, superficial, solid lesions should be approached as a possible sarcoma unless strong signs prove otherwise.8,18

    from;
    Synovial Sarcoma: Imaging
    Author: Michael J Duh, MD, Associate Physician, Kaiser Permanente
    Coauthor(s): Amilcare Gentili, MD, Professor of Clinical Radiology, University of California at San Diego; Consulting Staff, Department of Radiology, Thornton Hospital; Chief of Radiology, San Diego VA Health Care System; Sulabha Masih, MD, Associate Professor of Diagnostic Radiology, University of California, Los Angeles, David Geffen School of Medicine; Consulting Staff, Department of Radiology, Section of Musculoskeletal Radiology, West Los Angeles Veterans Affairs Medical Center
    Contributor Information and Disclosures
    Updated: Feb 15, 2010
    http://emedicine.medscape.com/article/396425-imaging



    Given the thickeness measured on US @ 3.6mm I would, during my US exam, see how it behaved with compression with probe, ie was it possible to see fluid motion and compress the deep/superficial edges completely together. If this was not possible it would unlikely be a bursa unless with hypertrophic synovium or very calcified.

    I would consider getting expert opinion elsewhere (me no expert!) if you are unsure just to be on safe side rather than go sticking needle in it.

    Also if lesion is an adventitious bursa, (most likley), I would be thinking that the mechanical cause needs sorting out since bursa is may be protectively useful unless it is some calicified vestige of prior problem.

    Hope that helps and worth considering in this case.

    cheers
    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  5. Saab

    Saab Member

    Much appreciated Martin, u are legend !

    Thanks for your time.:drinks

    I will refer for an MRI to be safe before probing into the lesion.

    Steve
     
  6. Mart

    Mart Well-Known Member

    Steve

    Thanks for comments; reallyI am simply (sadly?)an US nerd and believe it is a hugely underrated and miss and under used tool especially in those dealing with MSK problems in the foot/ankle.

    I would be inclined to phone the radiologist or whoever did the US exam of your pt, explain that you have some concerns about the possibility of malignancy and see if they are able to be definitive regarding if this lesion is a bursa or not. It may be really clear although possibly not reported if the lesion is fluid ot not. Normally, if there are several mm. soft tissue deep to a fliud or gel filled lesion an artifact called through projection occurs and this is an important consideration in interpretation of reflections. It maybe tricky with this lesion close to bone (US not penetrating bone) to appreciate this however in this case.

    good luck and let us know how this case proceeds

    cheers




    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
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