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Lipoma arborescens

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Lipoma arborescens in Radiology

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Lipoma arborescens

  2. 2. INTRODUCTION • Lipoma arborescens is a rare condition affecting synovial linings of the joints and bursae, with 'frond like' depositions of fatty tissue. • They account for less than 1% of all lipomatous lesions • Originally described by Hoffa, the macrospic frond like appearance was felt to resemble a tree in leaf; hence, the Latin term arborescens (meaning “tree- forming” or “treelike”)
  3. 3. EPIDEMIOLOGY • Patients typically present in the 5th-7th decades but the condition has also been reported in young • Usually these lesions are sporadic, however they can be seen in the setting of osteoarthritis, collagen vascular disorders or previous trauma
  4. 4. CLINICAL PRESENTATION • Painless joint swelling, frequently with an associated effusion. • The most frequent site of involvement is suprapatellar bursa of knee joint, and the disorder is usually unilateral • Occasional reports of hip, shoulder, wrist elbow are also reported. • Other joint involvement is uncommon. • Involvement of tendon sheath is even rarer.
  5. 5. PATHOLOGY • The normal synovium is replaced by hypertrophied villi demonstrating marked deposition of mature lipocytes within them
  6. 6. ASSOCIATIONS • joint effusion: very common • degenerative changes: common • meniscal tears: common • synovial cysts: uncommon • bone erosions: uncommon • chondromatosis: uncommon to rare • patellar subluxation: rare • discoid meniscus: rare
  7. 7. RADIOGRAPH • Occasionally plain films are able to detect fatty lucencies within a soft tissue lesion, although usually the large associated effusion dominates the film. • Coexistent degenerative changes are frequently present. • Bony erosions are uncommon
  8. 8. ULTRASOUND • Demonstrates a joint effusion with echogenic 'frond like' projections into the effusion.
  9. 9. CT • CT is able to demonstrate a low density intra-articular mass. • Aftter contrast: No or little if any enhancement is seen. • As joint fluid is volume-averaged with the lesion, it is of higher density than fat, but lower than water.
  10. 10. CT
  11. 11. MRI • MRI is the modality of choice for diagnosis. • T1: high signal • T2 & PD : less high signal • T2FS & STIR: low signal • Gradiant echo (GE): chemical shift artefact is sometimes seen at the fat-fluid interface • Typically, there is frond-like proliferation of fat-containing cells. Where effusions coexist, visualisation of the fronds is improved.
  12. 12. TREATMENT • The condition is benign and is cured by synovectomy. • Recurrence is uncommon
  13. 13. DIFFERENTIAL DIAGNOSIS • Loose bodies • often calcified • MRI hyopintense • Synovial osteochondromatosis/synovial chondromatosis • circumscribed loose bodies • erosions common • may calcify
  15. 15. DD • Pigmented villonodular synovitis (PVNS) • MRI demonstrates low signal on T2 weighted images • no fat signal • Synovial haemangioma • enhancement is more conspicuous • occasionally fluid-fluid levels are seen • Synovitis • thickened synovium but no fat signal
  16. 16. PVNS
  17. 17. REFERENCES • 1. Senocak E, Gurel K, Gurel S et-al. Lipoma arborescens of the suprapatellar bursa and extensor digitorum longus tendon sheath: report of 2 cases. J Ultrasound Med. 2007;26 (10): 1427-33. J Ultrasound Med (full text) - Pubmed citation • 2. Giant synovial lipoma arborescence of the right knee in a 76-year-old diabetic woman with purulent joint effusion. Çukur S, Belenli OK, Yücel I, Yazici B. Aegean Pathology Society, APJ, 3, 10–13, 2006. • 3. Meyers SP. MRI of bone and soft tissue tumors and tumorlike lesions, differential diagnosis and atlas. Thieme Publishing Group. (2008) ISBN:3131354216. Read it at Google Books - Find it at Amazon • 4. Manaster BJ, Disler DG, May DA et-al. Musculoskeletal imaging, the requisites. Mosby Inc. (2002) ISBN:0323011896. Read it at Google Books - Find it at Amazon • 5. Sheldon PJ, Forrester DM, Learch TJ. Imaging of intraarticular masses. Radiographics. 25 (1): 105-19. doi:10.1148/rg.251045050 - Pubmed citation • 6. Greenspan A, Jundt G, Remagen W. Differential diagnosis in orthopaedic oncology. Lippincott Williams & Wilkins. (2006) ISBN:0781779308. Read it at Google Books - Find it at Amazon • 7. Yan CH, Wong JW, Yip DK. Bilateral knee lipoma arborescens: a case report. J Orthop Surg (Hong Kong). 2008;16 (1): 107-10. Pubmed citation • 8. Coll JP, Ragsdale BD, Chow B et-al. Best cases from the AFIP: lipoma arborescens of the knees in a patient with rheumatoid arthritis. Radiographics. 2011;31 (2): 333-7. doi:10.1148/rg.312095209 - Pubmed citation • 9. Vilanova JC, Barceló J, Villalón M et-al. MR imaging of lipoma arborescens and the associated lesions. Skeletal Radiol. 2003;32 (9): 504-9. doi:10.1007/s00256-003-0654-9 - Pubmed citation • 10. Sanamandra SK, Ong KO. Lipoma arborescens. Singapore Med J. 2015;55 (1): 5-10. Free text at pubmed - Pubmed citation
  18. 18. Thank you