SDMRad

Radiological Findings, Disease course, and Management

 

                        Radiograph Of the Left Knee 

                            

                   AP                                      Lateral 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 Findings

• Gross soft-tissue swelling with supra patellar and knee joint effusion.

                                                               

                    High Resolution Ultrasound of Left Knee Joint

                                          

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 ​Findings

• Markedly thickened hypoechoic synovium with adhesions,

• Supra patellar effusion

• Joint effusion

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               Magnetic Resonance Imaging (MRI) of Left Knee                                                           

                                      

 

 

 

 

 

 

 

 

  Findings

• Large diffuse nodular synovial thickening in the knee joint and supra patellar bursa.

• Thickened synovium appears hypointense on all sequences  

• Erosion is seen involving tibial articular surfaces and non articular surfaces of femoral condyles and patella  

• Moderate suprapatellar and knee joint effusion is seen surrounded by thickened synovial rinds of hemosiderin-laden tissue 

• MRI findings suggest diffuse intraarticular PVNS of left knee joint

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Diagnosis

 Diffuse Intraarticular Pigmented Villonodular Synovitis of left knee joint

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Course

• Patient underwent left knee synovectomy and arthrotomy

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Histopathology

Hypertrophic synovial tissue with hemosiderin laden macrophages and multinucleated giant cells consistent with PVNS

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Discussion

• Pigmented villonodular synovitis (PVNS) is a benign neoplastic process that may involve synovium of joint, bursa and tendon sheath

• It is a locally aggressive, proliferative synovial tumor

• The diagnosis is often delayed because complaints and symptoms are nonspecific

• The diffuse intraarticular form of PVNS is monoarticular process and most frequently affects the large joints, with the knee involved in 66%–80% of cases

• Types

    Intraarticular 

    Synovium of the joint : diffuse or focal (PVNS)

 

    Extraarticular 

    Bursa (pigmented villonodular bursitis [PVNB])

    Tendon sheath (pigmented villonodular tenosynovitis [PVNTS])

• WHO Nomenclature

    Dffuse intraarticular form of PVNS - Diffuse-type giant cell tumor 

 

    PVNTS or PVNB - Giant cell tumor of the tendon sheath (GCTTS)

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Radiological Findings

Diffuse intraarticular PVNS

• Plain Radiography 

   Joint effusion, soft tissue swelling, absence of calcification, extrinsic      erosion of bone with rim of sclerosis, preservation of joint space, and      normal bone mineralization.

• Ultrasonography :

    Joint effusion, complex heterogeneous echogenic masses, markedly           thickened hypoechoic synovium & extrinsic erosion of underlying bone.       Doppler imaging reveals increased blood flow 

• Computed tomography 

    Synovial thickening which is  hyperdense relative to muscle due to           hemosiderin, joint effusion, extrinsic erosion of bone on both sides of       the joint & subchondral cyst formation

• Angiography 

    Prominent neovascularity

• Three-phase bone scintigraphy

    Increased radionuclide uptake in the blood flow and blood pool images       than the activity seen on delayed images

• Fluorine-18 fluorodeoxyglucose position emission tomography (PET) 

    Hypermetabolic activity

• Magnetic resonance imaging

    Joint effusion surrounded by thickened synovial rinds of hemosiderin-       laden tissue and heterogenous diffuse synovial thickening hypointense         on all sequences

    Low signal intensity also predominates on T2-weighted MR images, due       to preferential shortening of T2 relaxation time caused by hemosiderin,     an effect that is accentuated at higher field strength

    The blooming effect on gradient-echo images caused by magnetic             susceptibility artifact , which specifically signifies the presence of           hemosiderin as the cause of low signal intensity, is nearly pathognomic       of PVNS.

Differential Diagnosis on MRI

• Synovial hemangioma (presence of serpentine vascular channels).

• Hemophilic arthropathy (clinical history is suggestive)

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References

 

• Murphey et al. Pigmented Villonodular Synovitis with Radiologic-Pathologic Correlation. RadioGraphics 2008; 28:1493–1518.

• Al-Nakshabandi NA, Ryan AG, Choudur H, et al. Pigmented villonodular synovitis. Clin Radiol 2004; 59:414–420.

• Bravo SM, Winalski CS, Weissman BN. Pigmented villonodular synovitis. Radiol Clin North Am 1996; 34:311–326.

• Hughes TH, Sartoris DJ, Schweitzer ME, Resnick DL. Pigmented villonodular synovitis: MRI characteristics. Skeletal Radiol 1995;24:7–12.

• Jelinek JS, Kransdorf MJ, Utz JA, et al. Imaging of pigmented villonodular synovitis with emphasis on MR imaging. AJR Am J Roentgenol 1989;152: 337–342.

• Lin J, Jacobson JA, Jamadar DA, Ellis JH. Pigmented villonodular synovitis and related lesions: the spectrum of imaging findings. AJR Am J Roentgenol 1999;172:191–197.