A 56-year-old Woman with a Right Arm Mass

Abstract

A 56-year-old woman was admitted for a 5-year history of a painless right arm mass. The patient denied any recent enlargement. However, over the previous 2 years, the patient complained of gradually increasing numbness at the thumb, index finger, and middle finger of the ipsilateral arm. There was no history of trauma. Medical and family history was unremarkable.Physical examination revealed a soft, oval, deep palpable mass on the medial side of her right arm with a maximum diameter of 4 cm (Fig. 1). Passive and active range of motion of the right elbow and hand were unaffected. Neurologic examination was normal. Routine laboratory analysis including complete blood cell count, serum chemistries, erythrocyte sedimentation rate, and C-reactive protein were within normal limits.We performed plain radiography ( Fig. 2), ultrasonography (Fig. 3), and MRI (Fig. 4).Based on the history, physical examination, laboratory tests, and imaging studies, what is the differential diagnosis? Imaging InterpretationA frontal radiograph of the right upper arm showed a cluster of rounded calcifications in the soft tissues along the medial aspect of the mid humerus. No underlying osseous abnormality was noted (Fig. 2).Ultrasonography of the right arm showed a well-defined oval mass with heterogeneous internal echogenicity. The mass was closely related to the median nerve. Doppler examination revealed a moderate degree of vascularity within the lesion (Fig. 3).MRI showed a fusiform lesion with well-circumscribed borders along the posteromedial aspect of the biceps. The lesion was intermuscular and centered along the expected course of the median nerve. The normal median nerve could not be identified as a distinct structure at this level. The lesion was heterogeneous and slightly hypointense to muscle on T1-weighted images (Fig. 4A-B) and heterogeneously hyperintense on T2-weighted images. On postcontrast T1-weighted images (Fig. 4C-D), the mass enhanced in fairly uniform fashion. Differential Diagnosis Hemangioma SchwannomaEach author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution has approved the reporting of this case and that all investigations were conducted in conformity with ethical principles of research.

Ultrasonographic and Imaging Appearance of Peripheral Intraneural Vascular Anomalies: Report of Two Cases and Review of the Literature.

“…Of the 54 reported cases, it was performed only in 10, with 7 normal results. In three cases -two hemangiomas [6,23] and one arteriovenous malformation (our case no.2), phlebolyths or soft tissue calcifications were described and in only one case [6] a soft tissue mass was seen.…”

“…Pathology For 30 cases (55.55%) the final diagnosis was hemangioma, based on histopathological analysis. Of these tumors, 24 were located at the level of upper limb, affecting the median nerve (11 cases) [3,9,13,15,18,[23][24][25]30,32], ulnar nerve (8 cases) [8,16,19,26,31,33], digital branches of ulnar and radial nerves (4 cases) [7,20,29,31] and the inferior trunk of brachial plexus (1 case) [22]. The other 6 tumors were located at the level of lower limb, involving the sciatic nerve (2 cases) [27,31], peroneal nerve (3 cases) [5,11,19] and posterior tibial nerve (1 case) [14].…”

“…The other 6 tumors were located at the level of lower limb, involving the sciatic nerve (2 cases) [27,31], peroneal nerve (3 cases) [5,11,19] and posterior tibial nerve (1 case) [14]. These lesions were named differently by the authors: hemangioma [3,11,13,16,[18][19][20]22,24,26,31,33], intraneural hemangiomas [5,[7][8][9]15,23,29], endoneural hemangioma, intrinsic hemangioma [25] or capillary hemangioma [27,30,32]. Konet al [7] described one case in which the coexistence of an intraneural hemangioma and an extraneural cavernous hemangioma at the level of the digital branches of the ulnar nerve was observed.…”

“…Hemangiomas appeared as well-circumscribed masses, represented by a tissue component, surrounded by dilated arteries and drainage veins, sometimes with varicose aspect [15]. The phlebolyths induced small contrast filling defects [23].…”

“…Hemangiomas (17 cases) appear as tissue masses with hypo-or isosignal on T1 weighted sequences and T2 hypersignal, well delineated, with signal void due to multiple vessels, presenting early and heterogeneous enhancement after gadolinium [20,[22][23][24][25]27,29,[30][31][32][33].…”