The presence of soft tissue edema around a malignant musculoskeletal neoplasm can interfere with accurate local tumor
staging at magnetic resonance imaging. This article discusses and illustrates such edema, emphasizing means for avoiding
misinterpretation of edema and subsequent overstaging

Panicek, David M.

Schwartz, Lawrence H.

English

PubMed

David M. Panicek

Lawrence H. Schwartz

Crossref

Sarcoma (1997) 1, 189-191
CARFAX
ISSUES IN IMAGING
Soft tissue edema around musculoskeletal sarcomas at magnetic
resonance imaging
DAVID M. PANICEK & LAWRENCE H. SCHWARTZ
Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, USA
Abstract
The presence of soft tissue edema around a malignant musculoskeletal neoplasm can interfere with accurate local tumor
staging at magnetic resonance imaging. This article discusses and illustrates such edema, emphasizing means for avoiding
misinterpretation of edema and subsequent overstaging.
Key words: sarcoma, staging, soft tissue neoplasms, bone neoplasms, magnetic resonance imaging.
Accurate definition of the local extent of a sarcoma
is required to maximize the success of subsequent
interventions while minimizing the amount of tissue
(and function) that is removed. 1-5 Due to its excel-
lent ability to distinguish normal from abnormal
tissue, magnetic resonance imaging (MRI) is often
utilized for local staging of sarcomas. However, an
abnormal MRI signal is frequently present in soft
tissues surrounding a soft tissue sarcoma or the
extraosseous component of a bone sarcoma, charac-
terized by a very high signal on T2-weighted or
short tau inversion recovery (STIR) images.6-8 Such
a high signal is due predominantly to an increased
water content of the tissues, and is thus generically
referred to as ’edema’. (Peritumoral edema is less of
a problem during computed tomography (CT)
because soft tissue edema is less evident on CT
images.) The abnormal MRI signal likely corre-
sponds to the well-known ’reactive zone’ present in
the tissues around sarcomas,9 although this has yet
to be rigorously proven. Potentially, the reactive
zone may contain viable tumor, but the entire reac-
tive zone cannot be excised in every case if the
affected limb is to be preserved in a functional state.
Peritumoral edema can extend for considerable dis-
tances as the fluid is ’squeezed’ along by muscle
contractions.
As a practical matter, failure to distinguish tumor
and peritumoral edema on MRI can result in over-
staging of tumor extent (Fig. 1). Such overstaging is
particularly problematic with the STIR sequence
due to its increased sensitivity to increased water
content in a tissue. 1 Therefore, reliance cannot be
placed on STIR sequences alone when determining
the local extent of a sarcoma.
One helpful MRI feature that has been described
is the muscle texture sign.ix On thin (e.g. 5 mm)
axial T1-weighted images of normal muscles, intra-
muscular fat present between groups of fascicles
often produces a typical macroscopic ’marbled’ par-
enchymal pattern, which is usually preserved even in
the presence of edema. In contrast, tumours do not
exhibit such a pattern of fat within them. Thus,
when confronted with an abnormal signal in soft
tissues on a T2-weighted image, correlation should
be made with the corresponding T1-weighted image
obtained at the same anatomic location to deter-
mine whether the muscle texture sign can be appre-
ciated in that area. The presence of the muscle
texture sign effectively precludes the presence of
macroscopic tumor in that area; however, lack of the
sign does not prove the presence of tumor.I
Also, dynamic intravenous administration of
gadolinium-based contrast material may provide dif-
ferential enhancement of tumor and peritumoral
edema. 12 In general, malignant turnouts enhance
faster than edematous tissue, so that MRI per-
formed during and immediately after rapid intra-
venous administration of contrast material may
cause relatively greater enhancement of the tumor
than the peritumoral edema. Of note, non-dynamic
imaging is not reliably helpful in this regard. 13’14
Awareness of peritumoral edema and means
to facilitate its recognition is important to avoid
overstaging the soft tissue extent of a sarcoma at
MRI.
Correspondence to: D. M. Panicek, Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York,
NY 10021, USA. Tel: + 212 639 5825; Fax: + 212 794 4010; E-mail: panicekd@mskcc.org
1357-714X/97/030189-03 $9.00 (C) 1997 Carfax Publishing Ltd
190 D. M. Panicek & L. H. Schwartz
Fig. 1. Clear cell sarcoma
(melanoma ofsoft parts) in proximal
calf. (a, b) Axialfat-suppressedfast
spin-echo T2-weighted (TR 4000
ms/TE 105 ms) images, with (a)
located 3 cm cephalad to (b). Exten-
sive mass-like areas ofabnormal high
signal (asterisks) are evident in the
soft tissues of the proximal calf.
Differentiation of tumor and peritu-
moral edema is not evident on these
images alone. (Arrowhead in (a)
denotes a tumor deposit within the
tibial marrow.) (c) Axial 6-mm thick
Tl-weighted (700/14) image
obtained at same anatomic level as
(a) shows large, bilobed tumor mass
(long arrows) without evidence of
high-signalfat streaked within it. In
contrast, note the streaky high-signal
fat (short arrows) present within
normal muscle near the tumor mass.
(Arrowhead in (c) denotes a tumor
deposit within the tibial marrow.) (d)
Axial 6-mm-thick Tl-weighted
(700/14) image obtained at same
anatomic level as (b) shows normal
high-signal fat (arrows) streaked
within muscles (i.e. normal muscle
texture sign), indicatinglack oftumor
mass in this region. Abnormal high
signal present on the T2-weighted
image in (b) thus was due to peritu-
moral edema. (e) Sagittal T2-
weighted (4000/105) image
demonstrates the rounded tumor mass
(M) with extensive surrounding
edema, both having high signal
intensity.
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Soft Tissue Edema Around Musculoskeletal Sarcomas at Magnetic Resonance Imaging

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Soft Tissue Edema Around Musculoskeletal Sarcomas at Magnetic Resonance Imaging

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