CASE 142
By: Dr. Nizar Al-Nakshabandi MD, FRCPC
HISTORY: 20-year-old female with elbow pain.
What are your findings?
What is the differential diagnosis?
What are the causes?
FINDINGS:
Sagittal gradient echo fat suppressed images [A] demonstrate mass like synovial proliferation with lobulated margins localized to the elbow joint with low signal intensity and blooming due to hemosiderin deposition.
Sagittal T1 weighted images with gadolinium with fat suppression demonstrate variable enhancement of the synovial lining and of the joint itself.
DIFFERENTIAL DIAGNOSIS:
· Pigmented villonodular synovitis.
· Hemangioma.
· Lipoma arborescens.
· Synovial chondromatosis.
· Siderotic synovitis.
DIAGNOSIS:
Pigmented villonodular synovitis.
PEARLS AND DISCUSSION:
Is a proliferative condition of the synovial membrane. If inside the joint it is called PVNS, if it is outside the joint in the bursa or along the tendons it is considered giant cell tumor of the tendon sheath. Pathologically they can look like an aggressive neoplasm such as rhabdomyosarcoma or synovial sarcoma therefore imaging plays a role in helping the pathologist.
PVNS appears in the second to fifth decade of life. No preferred gender.
Is is thought that PVNS is a reactive chronic inflammation. However, there is a rare malignant transformation potential.
The knee is by far the most common location. Followed by the hip, ankle, shoulder, elbow and of the other joints.
Treatment is by complete synovectomy. Which results in accelerated osteoarthritis therefore special therapy with external beam radiotherapy offers excellent control. Furthermore, intra-articular injection of the Ytrium 90 is an alternative.
The recurrence rate after synovectomy is in the range of 15%.
FURTHER READING:
1. Bravo SM, Winalski CS, Weissman BN. Pigmented villonodular synovitis. Radiol. Clin. North Am. 1996;34 (2): 311-26, x-xi
2. Murphey MD, Rhee JH, Lewis RB et-al. Pigmented villonodular synovitis: radiologic-pathologic correlation. Radiographics. 28 (5): 1493-518. doi:10.1148/rg.285085134 –
3. N.A Al-Nakshabandi, A.G Ryan, H Choudur, W Torreggiani, S Nicoloau, P.L Munk, K Al-Ismail. Pigmented villonodular synovitis, Clinical Radiology, Volume 59, Issue 5, Pages 414-420
