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Soft Tissue Tumors about the Shoulder

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284

Soft Tissue Tumors about the Shoulder

Filip M. Vanhoenacker, MD, PhD1,2,3 Koenraad L. Verstraete, MD, PhD3

1 Department of Radiology, Antwerp University Hospital, Edegem,
Belgium
2 Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen,
Belgium
3 Department of Radiology, Ghent University Hospital, Ghent, Belgium
Address for correspondence Filip M. Vanhoenacker, MD, PhD,
Department of Radiology, AZ Sint-Maarten, Rooienberg 25, 2570
Duffel, Belgium (e-mail: filip.vanhoenacker@telenet.be).

Semin Musculoskelet Radiol 2015;19:284–299.

Abstract Soft tissue tumors (STTs) are not infrequent about the shoulder girdle. This article
Keywords provides a short overview of useful parameters in grading and characterization of those
► soft tissue tumor lesions. The most frequent histologic types of STT about the shoulder girdle are also
► ultrasonography discussed. Benign STTs and mimickers of STTs are emphasized because precise imaging
► magnetic resonance characterization of aggressive STTs is much more difficult than of their benign
imaging counterparts. Besides evaluation of the lesion’s extent, a major role for imaging is to
► shoulder select those lesions that should undergo biopsy. MRI is the preferred imaging technique.

The World Health Organization 1 recognizes four categories
of soft tissue tumors (STTs): benign, intermediate
(locally aggressive), intermediate (rarely metastasizing),
and malignant. Pseudotumoral lesions may mimic lesions
of neoplastic origin. Although imaging does not replace
histology and is not always able to make a definitive
distinction among those four groups, a large number of
predominantly benign lesions have a characteristic imag-
ing appearance obviating the need for further histologic
confirmation. Unfortunately, a tissue-specific diagnosis
(characterization) cannot be obtained for all STTs.
This article focuses on STTs about the shoulder and pro-
vides a short overview of the parameters that can help grade
and characterize those lesions. In addition, a short overview
of the most frequent histologic types of STTs about the
shoulder girdle is provided. Benign STTs and mimickers of
STTs are emphasized because precise histologic characteriza-
tion of aggressive STTs is more difficult than in their benign
counterparts.
Nonimaging Parameters
Location about the Shoulder Joint and Patient’s Age
The overall annual clinical incidence of benign STTs is 250
per 100,000 as compared with 3 per 100,000 for malignant
ones. Overall, 70% of benign and 80% of malignant tumors
can be classified in six and seven “diagnostic categories,”
respectively (►Table 1).2,3 If an STT is located about the
shoulder girdle, the differential diagnosis can be further
narrowed, particularly when the age of the patient is taken
into account2,3 (►Table 2).
Multiplicity
If multiple or bilateral soft tissue lesions are found about the
shoulder girdle, pseudotumoral lesions (such as elastofi-
broma dorsi and injection granuloma in the deltoid muscle
in bodybuilders) should be considered along with neurogenic
tumors and soft tissue metastases (►Figs. 1 and 2).
Imaging Techniques and Imaging
Parameters
Plain Films
Plain radiography is highly insensitive for the detection of
SSTs and of little help in tissue characterization. Certain STTs,
however, contain intralesional calcifications or ossifications
(►Table 3) that may increase specificity in the diagnosis4,5
(►Fig. 3). An anaerobic soft tissue infection or abscess may
contain air bubbles.
Computed Tomography
Today, computed tomography (CT) is surpassed by MRI for
local evaluation of SSTs because of its relatively low contrast
resolution and radiation constraints (►Fig. 4). CT may be

Issue Theme The Shoulder: Back to Copyright © 2015 by Thieme Medical DOI http://dx.doi.org/
Basics; Guest Editors, Andrew Grainger, Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1549322.
MRCP, FRCR and Philip Robinson, MB ChB New York, NY 10001, USA. ISSN 1089-7860.
(Honours), MRCP, FRCR Tel: +1(212) 584-4662.
 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete 285

Table 1 Major diagnostic group of soft tissue tumors

70% Benign 80% Malignant

Lipoma and variants Myxofibrosarcoma
Fibrous histiocytoma Liposarcoma
Nodular fasciitis Leiomyosarcoma
Hemangioma Malignant peripheral nerve sheath tumor
Fibromatosis Synovial sarcoma
Neurofibroma-schwannoma Fibrosarcoma
Sarcoma not otherwise specified

useful, however, for the demonstration of subtle intralesional
calcifications/ossifications or in case of contraindications for
MRI (►Fig. 4). Low-dose CT remains the preferred modality
for distant staging of malignant STTs in search of metastatic
disease and for guiding biopsy.
Ultrasound
Ultrasound (US) is often used for the initial evaluation of
superficial and cystic soft tissue lesions. It is particularly
useful for characterization of benign periarticular cystic
lesions (ganglion cyst or synovial cysts), obviating further
imaging. In most cases, true cystic lesions are intimately
related to the adjacent joint. Benign and malignant myxoid
tumors should not be misinterpreted as true cystic lesions.
Lesions that are remote from the shoulder joint have a firm
consistency; large lesions should be handled with suspicion.
Moreover, any lesion with increased (color) Doppler flow
should be regarded as a potential malignancy. Further evalu-
ation with MRI (including intravenous [IV] injection of gado-
linium contrast) is imperative in those scenarios.
US is nonspecific for the characterization of solid STTs and
not suited for evaluation of large and deeply located lesions.
Even in benign-looking subcutaneous lipomas or epider-
moid cysts, meticulous correlation with clinical findings is
warranted so as not to overlook a potential malignancy.
A clear history of trauma is required to make the diagnosis
of an intramuscular hematoma. Careful clinical and imaging
follow-up are needed.
Magnetic Resonance Imaging
MRI is currently the preferred imaging technique in the
diagnostic setting of STTs.4–6 Differentiation between benign

Table 2 Most frequent soft tissue tumors about the shoulder, upper arm, and axilla

Children Adults
Benign Benign
Hemangioma Lipoma and variants
Lymphangioma Elastofibroma dorsi
Nodular fasciitis Fibrous histiocytoma
Lipoblastoma Nodular fasciitis
Hemangioma
Neurogenic tumors
Myxoma
Desmoid
Malignant Malignant
Rhabdomyosarcoma (alveolar soft part type) Myxofibrosarcoma
Hemangiosarcoma Liposarcoma
(angiomatoid) malignant fibrous histiocytoma Sarcoma not otherwise specified
Fibrosarcoma Malignant peripheral nerve sheath tumor
Leiomyosarcoma
Synovial cell sarcoma
Fibrosarcoma

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286 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete

Fig. 1 Elastofibroma dorsi. (a) Clinical picture of the patient showing a left periscapular soft tissue mass (black arrow). A similar smaller lesion is
visible at the right side (white arrow). (b) Ultrasound of the lesion at the left side shows alternating layers of hyperechoic fibroelastic tissue (white
asterisk) and hypoechoic bands (white arrowheads). (c) Coronal T1-WI demonstrates a bilateral fusiform soft tissue mass between the serratus
anterior muscle and the thoracic wall (white arrows). The lesion has a multilayered appearance, consisting of alternating bands of low signal with
intermingled fatty components, resembling lasagna. (d) Axial T2-WI showing the intimate relationship of the lesion with the apex of the scapula,
the serratus anterior muscle, and the thoracic wall (white arrows).

and malignant and definition of malignancy grade (grading)
and prediction of tissue-specific diagnosis (characterization)
on imaging yield the best results if multiple MR parameters
are combined: size, morphology, signal intensities on T1- and
T2-weighted images (WI), fat suppression (FS), homogeneity,
and pattern and degree of contrast enhancement on (dynam-
ic) contrast-enhanced MRI.7,8
Morphological criteria are particularly helpful in the
prediction of a tissue-specific diagnosis. Typical morpho-
logical signs are the lasagna sign in elastofibroma dorsi
(►Fig. 1), broccoli sign in lipoma arborescens, target sign in
neurofibroma, and the fluid-fluid sign in hemangioma/
lymphangioma and other STTs in which hemorrhage
occurred.
Based on the analysis of signal intensity (SI) on T1- and T2-
WI, four main groups of STTs can be distinguished. Use of FS
techniques may be helpful to differentiate between lipoma-
tous and nonlipomatous components.
Lesions that are of high SI on T1-WI similar to subcutane-
ous fat, intermediate on turbo spin-echo T2-WI, and sup-
pressed equally to fat on FS images (group I) may indicate the
presence of fat.
Intermediate to high SI on T1-WI compared with normal
muscle and a high SI on T2-WI (group 2) may be due to
subacute blood, slow-flowing blood in slow-flow vascular
malformations, high protein content in lymphangiomas, and
melanin in malignant melanoma and clear cell sarcomas. On
FS images, there will be an absence of signal drop in these
lesions.
A combination of low SI on T1-WI and high SI on T2-WI
(group III) is seen in cystic lesions (ganglia, paralabral cysts)
(►Fig. 5) and myxoid-containing tumors such as myxoma
(►Fig. 6), myxofibrosarcoma, and myxoid liposarcoma.9
Myxoid-containing lesions show a moderate decrease in SI
after FS when compared with non-FS T1-WI (►Fig. 6).
Low SI on T1-WI and T2-WI (group IV) can be caused by
fibrous tissue in desmoids (►Fig. 7) and other fibromatoses,
hemosiderin in old hematomas, and pigmented villonodular
synovitis (PVNS). Low SI can also be due to hypercellularity in
high-grade malignancies and lymphomas (►Fig. 8). The
presence of blooming on gradient-echo sequences indicating
susceptibility artifacts due to hemosiderin is particularly
helpful to distinguish PVNS from other lesions with a low
T1 and T2 signal.
►Table 4 summarizes the parameters that are helpful in
the differential diagnosis between benign and potentially
malignant lesions.
A second opinion report by a center with major expertise
in STTs may improve the overall accuracy of grading and
characterization from 83% up to 92%.10
The role of advanced MR techniques such as diffusion-
weighted imaging, diffusion tensor imaging, and MR spec-
troscopy for tumor characterization and follow-up after
treatment is still debated.11

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 Soft Tissue Tumors about the Shoulder
Fig. 2 Bilateral intramuscular pseudotumor in the deltoid muscle due
to intramuscular injection of anabolics in a bodybuilder. (a) Axial T1-WI
of the right shoulder shows a heterogeneous mass lesion containing
multiple fatty components (arrows). (b) Axial T1-WI and (c) fat-
suppressed (FS) T2-WI of the left shoulder depicts a mass with a
T1-hyperintense fatty component and marked fat-fluid level (arrow)
(reprinted with permission from Ardies et al19).
Vanhoenacker, Verstraete 287
Other Imaging Techniques and Diagnostics Techniques
Cytogenetics and molecular genetics play an increasing role in
tissue-specific diagnosis in some histologic types of tumors.12
Positron-emission tomography (PET)-CT and PET-MRI are
evolving techniques that may be useful to target active
metabolic areas within an STT.13
Any soft tissue lesion suspicious for malignancy should be
biopsied. Most biopsies are performed under imaging (CT or
US) guidance. Close cooperation with the oncologic surgeon
and a thorough knowledge of compartmental anatomy are
mandatory. The anticipated needle path should be discussed
with the surgeon to avoid local metastatic seeding in multiple
compartments.14
Most Frequent Histologic Types of Soft Tissue
Tumors about the Shoulder
Pseudotumors
Benign Cystic Lesions
Ganglion cysts are relatively rare about the shoulder joint
compared with periarticular cysts about the knee, wrist, and
ankle. Cysts in the spinoglenoid notch are often associated
with labral lesions15 (►Fig. 5). Cystic lesions adjacent to the
acromioclavicular (AC) joint are often secondary to a long-
standing rotator cuff tear, in which there is communication of
joint fluid of the glenohumeral joint with the AC joint through
a large rotator cuff tear16 (►Fig. 9).
Scapulothoracic bursitis is an adventitious bursitis, sec-
ondary to repeated friction between the scapula and the
thoracic wall. Patients often present with periscapular pain,
particularly during motion, often accompanied by a grinding
or snapping noise (crepitus). US and MRI show a fluid-filled
structure17 (►Fig. 10). Occasionally, the SI on T1-WI can be
hyperintense due to protein content. Sometimes a fluid-fluid
level is present. On contrast-enhanced MRI, the bursal wall
may enhance. Plain films and CT may be useful to demon-
strate and underlying bony abnormalities (e.g., exostosis).
Other Pseudotumoral Lesions
Elastofibroma dorsi consists of entrapped fat within a fibrous
matrix. It occurs almost exclusively in the subscapular region
in middle-aged to older patients, has an oval or lenticular
shape, and can be bilateral. The lesion is also secondary to
mechanical friction between the scapula and chest wall. On
US and MRI, the lesion has a multilayered appearance,
resembling lasagna (►Fig. 1). On MRI, the alternating bands
of low SI correspond to fibrous components, whereas inter-
mingled fatty components are similar to fat on all pulse
sequences18 (►Fig. 1).
Bilateral intramuscular pseudotumor secondary to intra-
muscular injection of anabolic steroids in the deltoid muscle
may occur in bodybuilders. Histologically, there are several
possible causative mechanisms explaining the origin of these
soft tissue lesions: infectious nonsterile injections caused by
needle sharing, physical trauma induced by recurrent intra-
muscular injections, or inflammatory response against the
steroid agent or oil-based components mixed with the
Seminars in Musculoskeletal Radiology Vol. 19 No. 3/2015
288 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete

Table 3 Calcifications and ossifications in soft tissue tumors and pseudotumors

Morphology Benign Malignant

Popcorn, ring, and arc-like Extraskeletal chondroma, synovial chondromatosis Extraskeletal chondrosarcoma
Rounded/circular (phleboliths) Low-flow vascular lesion
Amorphous Hydroxyapatite deposition Synovial cell sarcoma
Chondroid lipoma Extraskeletal osteosarcoma
Ewing/Primitive neurectodermal tumor
Multinodular Tumoral calcinosis Calcified metastasis
Peripheral Myositis ossificans
Extraskeletal aneurysmal bone cyst
Bridging Fibrodysplasia ossificans progressiva

steroid. The lesion may contain areas of muscle necrosis with
cystic transformation and fibrosis. A fat-fluid level on MRI can
occur due to repeated trauma and fat necrosis (►Fig. 2). The
heterogeneous imaging appearance may mimic liposarcoma
or any other sarcoma, if the clinical history of the patients is
not taken into account.19
Other complications of deltoid injection are soft tissue
abscess and myositis ossificans.20,21 A soft tissue abscess is of
low to intermediate SI on T1-WI, high SI on T2-WI, and
demonstrates peripheral rim enhancement following IV in-
jection of gadolinium contrast.
Myositis ossificans resulting from trauma or overuse is less
frequent about the shoulder girdle than in the lower extrem-
ities.20,21 Imaging findings are time dependent. Faint periph-
eral calcifications may appear after 7 to 10 days of
presentation on plain films. This subtle peripheral calcifica-
tion may be more obvious on US or CT. MRI is nonspecific in
this stage. After 4 weeks to 6 months, well-defined peripheral
calcification and coarser central calcification become appar-
ent on plain radiographs and CT. The ossification pattern is
centripetal. MRI shows a peripheral rim of low SI on all pulse
sequences, corresponding to calcifications. The SI of the

Fig. 3 Use of plain radiographs in the characterization of secondary osteochondromatosis of the shoulder. (a) Anteroposterior radiograph and (b)
endorotation view shows multiple large ossified nodules of different size within the glenohumeral joint and at the bicipital groove (black arrows).
Note degenerative joint disease with large osteophyte formation at the medial proximal humerus (black arrowhead). (c) Sagittal and (d) axial MR
arthrogram shows multiple filling intra-articular nodules within the tenosynovial sheath of the long head of the biceps at the bicipital groove.

Seminars in Musculoskeletal Radiology Vol. 19 No. 3/2015

 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete 289

center of the lesion varies according to the degree of calcifi-

Fig. 4 Computed tomography scan in an 80-year-old patient with a
histologically proven myxofibrosarcoma. MRI was not possible due to a
pacemaker. Note the presence of a large low-density mass in the
deltoid muscle (containing myxoid tissue). There is irregular delinea-
tion of the inner margin of the lesion (black arrow).
cation. Perilesional edema gradually disappears after 4 weeks.
After 6 months, the calcification-ossification front further
develops following a “zoning” or centripetal pattern, with
lamellar bone at the periphery proceeding toward the cen-
ter.22,23 Dense calcification or ossifications are clearly visible
on plain films and CT, whereas MRI shows low SI on all pulse
sequences. Ossifications may show high SI on T1-WI due to
intralesional bone marrow formation.22,23
Lipoma arborescens consists of subsynovial fatty prolifera-
tion, secondary to chronic synovitis. MRI demonstrates a
frond-like fatty mass associated with joint effusion (►Fig. 11).
Focal myositis is a rare painful soft tissue pseudotumor,
usually affecting the lower extremities (50%) and rarely the
shoulder girdle.24,25 The process is usually limited to one
muscle and often self-limiting, but a third of patients with
focal myositis develop polymyositis.24 US and MRI demon-
strate focal enlargement of the muscle, with typical sparing of
the internal muscle fibers. T2-WI images show heterogeneous
increased signal within the affected muscle (►Fig. 12).
Enhancement is variable.25
Benign Tumors
Lipoma and Lipoma Variants
Lipoma is a common mesenchymal tumor about the shoulder
presenting as a painless slow-growing mass, typically

Fig. 5 Paralabral cyst in the spinoglenoid notch of the left shoulder. (a) Transverse ultrasound showing a well-defined anechogenic structure
within the spinoglenoid notch (white arrows). (b) Axial T2-WI and (c) coronal fat-suppressed (FS) T2-WI confirms the cystic nature of the structure
(white arrows). (d) Axial FS T1-WI MR arthrogram shows a posterior labrum tear and contrast leakage along the posterior glenoid pointing to the
lesion in the spinoglenoid notch (arrow). There is no filling of the lesion, related to inspissated myxoid contents of the cystic lesion (white asterisk).

Seminars in Musculoskeletal Radiology Vol. 19 No. 3/2015

290 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete

Fig. 7 Aggressive fibromatosis (desmoid) in the right deltoid muscle.

Fig. 6 Intramuscular myxoma. (a) Axial fat-suppressed (FS) T1-WI
shows an intramuscular lesion that is of slightly lower signal intensity
than muscle (black arrows). (b) Coronal FS T2-WI shows a high signal
and a hyperintense tail of high signal at the superior pole of the lesion
(white arrow), due to leakage of myxoid tissue through an incomplete
capsule. (c) Axial T1-WI after gadolinium contrast shows moderate
smokelike enhancement.
(a) Coronal T1-WI and (b) coronal short tau inversion recovery shows
an ill-defined mass in the deltoid muscle. The lesion is heterogeneous
on both pulse sequences containing intralesional areas of low signal
intensity. (c) Axial fat-suppressed T1-WI after administration of gad-
olinium contrast shows heterogeneous enhancement and ill-defined
margins.

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 Soft Tissue Tumors about the Shoulder
Fig. 8 Cutaneous B-cell lymphoma with extension into the subcutis of the right upper arm. (a) On axial T2-WI and (b) sagittal fat-suppressed (FS)
T2-WI, the mass is of relatively low signal compared with the subcutaneous fat (white arrows). (c) Axial FS T1-WI after gadolinium contrast shows
homogeneous enhancement of the lesion. Central necrosis is unusual in lymphoma (white arrows).
affecting middle-aged and elderly patients. It may be either
superficially or deeply located within or between the
muscles.26
Superficial lipomas27 have an oval or fusiform shape; they
are compressible and most often hyperechogenic on US.
There is no intralesional power Doppler signal.
Lipomas have a low attenuation value ( 100 HU) on CT.
On MRI, lipoma is of homogeneous high SI on T1-WI and
intermediate SI on T2-WI, and it does not enhance. Thin septa
or residual muscle fibers between the fatty lobules may be
seen on CT as well on MRI and may enhance slowly28
(►Fig. 13).
Madelung disease is a diffuse symmetrical deposition of fat
in the neck and shoulder area.
An atypical lipomatous tumor (formerly known as well-
differentiated liposarcoma) is an STT of intermediate grade.1
On MRI, the lesion resembles a lipoma, but there are thick
intralesional septa or nodules of low SI on T1-WI, high SI on
T2-WI, and fast enhancement.28 ►Table 5 summarizes other
differential diagnostic parameters of benign versus malignant
fat-containing tumors (liposarcoma).
Certain histologic subtypes of benign lipomatous tumors,
such as lipoblastoma and hibernoma, may simulate malig-
nancy if the patient’s age and location is not taken into
account. Lipoblastoma is a painless well-encapsulated lesion
Table 4 General MR Imaging features suggesting malignancy
• Large size (> 3 cm)
• Ill-defined margins
• Inhomogeneity on all pulse sequences
• Intralesional hemorrhage or necrosis
• Marked and peripheral enhancement pattern
(with papillary projections) on static contrast examination
• Rapid enhancement with steep slope on dynamic
contrast examination
• Extracompartmental extension
• Invasion of adjacent bones and neurovascular bundles
Vanhoenacker, Verstraete 291
containing lipoblasts. It is typically seen in young children
and may occur about the shoulder girdle. Lipoblastoma often
shows tumor inhomogeneity on T1- and T2-WI with areas of
nonlipomatous components interspersed within a fatty le-
sion. Intralesional nonlipomatous components may slowly
enhance on contrast-enhanced MRI29 (►Fig. 14). The lesion
may mimic a liposarcoma, if the young age of the patient is
not taken into account.
Hibernoma contains brown fat and has a predilection for
the shoulder girdle and axilla.30,31 The lesion is often inho-
mogeneous, has an intermediate density on CT, and a signal
between fat and muscle on T1-WI, and there is often incom-
plete FS. The SI is variable on T2-WI. Enhancement is nonho-
mogeneous and moderate. The clue to the correct imaging
diagnosis is the location on areas where brown fat accumu-
lates. However, histology is required for a definitive
diagnosis.31
Neurogenic Tumors
Schwannomas and neurofibromas are histologically two
distinct neurogenic tumors that often are difficult to distin-
guish on imaging because of overlapping imaging signs.
When a well-delineated round or fusiform lesion is seen on
the course of a peripheral nerve, the diagnosis of a neurogenic
tumor should be considered. An entering/exiting nerve on
longitudinal US or MR images is highly suggestive for a
neurogenic tumor (►Fig. 15). Other imaging features of
neurogenic tumors consist of the split-fat sign and associated
muscle atrophy.32
MRI features suggesting schwannoma are a fascicular
appearance on axial T2-WI caused by enlarged nerve bundles,
a thin hyperintense rim on T2-WI, and diffuse enhance-
ment.32 Ancient schwannoma may show central necrosis33
(►Fig. 16).
Imaging findings rather suggestive of neurofibroma in-
clude a target sign (high SI in the periphery and low to
intermediate SI in the center) on T2-WI and central
enhancement.32
Plexiform neurofibroma (►Fig. 17) is a subtype of neuro-
fibroma pathognomonic of neurofibromatosis type 1 (NF I).
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292 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete

Fig. 9 Acromioclavicular cyst in a large rotator cuff tear. (a) Clinical picture of the patient showing a mass on top of the acromioclavicular (AC)
joint. (b) On plain radiographs, a nonspecific soft tissue mass (white arrows) is seen at the superior aspect of the AC joint. There is marked elevation
of the humerus toward the acromion, which is indicative of a large long-standing rotator cuff tear. (c) Ultrasound shows a large cystic lesion
communicating with the AC joint (black arrow). (d) Oblique coronal T2-WI confirms a large full-thickness rotator cuff tear. There is continuity of
joint fluid within the glenohumeral joint and the AC cyst (white arrows) that also contains some internal hypointense debris.

Expansion and distortion of large segments of a nerve and its
branches may create a “bag of worms” appearance.34 In NF 1,
there are usually multiple neurogenic tumors, and malignant
degeneration should be suspected in large inhomogeneous
lesions. Imaging parameters that help to distinguish benign
from malignant peripheral nerve sheath tumors are summa-
rized35 in ►Table 6.
Benign Vascular Tumors of Soft Tissue
Vascular anomalies of the soft tissues comprise a heteroge-
neous spectrum of lesions, often seen in young patients.1
Currently, the International Society for the Study of Vascular
Anomalies integrated these classifications by defining two
main categories of vascular anomalies: vascular tumors and
vascular malformations.36
A hemangioma represents a true vascular tumor consisting
of endothelial proliferation and hyperplasia, usually occur-
ring in the first few weeks of life, followed by gradual
involution at the age of 7 to 10 years. The diagnosis is often
made clinically, and imaging may be done solely for evalua-
tion of the lesion’s extent. The lesion is well delineated and is
of high SI on T2-WI and intermediate SI on T1-WI. Gradual fat
replacement may appear during involution of the lesion.
There is marked homogeneous enhancement.
Vascular malformations arise from dysplastic vascular
channels with normal endothelial turnover, growing propor-
tionally with the child without regression with age. Vascular
malformations are further subdivided according to their flow
dynamics as low-flow malformations (venous, lymphatic,
capillary, capillary-lymphatic, and capillary-lymphatic-
venous) and high-flow malformations (arteriovenous mal-
formations and arteriovenous fistulas).36 Plain films and CT
may show intralesional phleboliths. Color Doppler US may
differentiate between low-flow (no Doppler signal) and high-
flow (low resistance flow pattern) vascular malformations.4
On MRI, venous malformations are of high SI on T2-WI and
intermediate SI on T1-WI. The shape is often multilobular,
resembling a “bunch of grapes” (►Fig. 18). Occasionally
hemorrhage or high protein content may cause fluid-fluid
levels. A peripheral fat rim may be seen on T1-WI.4,36
High-flow vascular malformations may show signal
voids on all pulse sequences and demonstrate serpiginous
and rapid enhancement on dynamic contrast-enhanced
MRI. 36
Tumors of lymphatic origin may involve the shoulder girdle
and axilla, preferentially in patients < 5 years of age.3 Fluid-
fluid levels may be seen if intralesional hemorrhage has
occurred.36

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 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete 293

Fig. 10 Subscapular bursitis. (a) Axial T2-WI shows a fluid-filled structure between the right scapula and the thoracic wall (black arrows). (b) Axial
fat-suppressed T1-WI after gadolinium contrast shows only subtle wall enhancement of the lesion (white arrows).

Fig. 11 Lipoma arborescens associated with increased joint fluid due to a large full-thickness tear of the rotator cuff. (a) Sagittal T1-WI and (b)
coronal T2-WI show a fat-containing lesion with a typical frond-like morphology (resembling the surface of broccoli) within the axillary recess of
the right shoulder (arrows).

Synovial Osteochondromatosis It is a neoplastic disorder resulting in multiple small

Primary osteochondromatosis is rare in the glenohumeral (osteo)cartilaginous nodules originating in the outer lin-
joint and even more rarely involves the extra-articular space, ing of the synovial membrane of joint or tendon
such as the subacromial bursa.37 sheath.4,32

Fig. 12 Focal myositis in the right latissimus dorsi muscle. (a) Axial and (b) longitudinal ultrasound shows a fusiform swelling of the muscle belly
(arrows) with internal sparing of the muscle bundles (asterisks). (c) On fat-suppressed T2-WI, the lesion is of heterogeneous signal (arrows) with
intralesional bundles of spared muscle isointense to muscle (asterisks).

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294 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete

Fig. 13 Intramuscular lipoma in the deltoid muscle. (a) Axial, (b) oblique sagittal T1-WI, and (c) axial fat-suppressed intermediate WI show a large
well-delineated mass within the deltoid muscle. The signal of the lesion is similar to subcutaneous fat on all pulse sequences. Note some thin
intralesional septa (black arrows), corresponding to residual intramuscular muscle fibers.

Table 5 Differential diagnostic criteria on MRI between lipoma and liposarcoma

Lipoma Liposarcoma
Location Subcutaneous fat or muscle Deep location (intramuscular,
retroperitoneum)
Size < 5 cm > 5 cm
Shape Round, oval or fusiform Multilobulated
Contents Homogeneous fat-like or thin Inhomogeneous with intralesional
internal (fibromuscular) non–fat-containing noduli or septa thicker than 2 mm
septa thinner than 2 mm
Enhancement No enhancement Intralesional foci of enhancement

Secondary osteochondromatosis is more common in the
shoulder, developing due to cartilage release within the joint.
Large ossified nodules of different sizes may be seen, often
extending within the tendon sheath of the long head of the
biceps. Associated osteoarthritis is often visible on plain
radiography or CT32 (►Fig. 3).
Myxoma
Myxoma contains abundant avascular myxoid stroma in
which a small number of cells are embedded. The muscles
of the shoulder and upper arm is a common site of involve-
ment. Mazabraud syndrome is an association between myx-
oma and polyostotic fibrous dysplasia. On MRI, myxomas are
of low SI on T1-WI compared with muscle and of high SI on
T2-WI. On T2-WI, there is often a hyperintense tail of high SI
in the adjacent muscle, due to leakage of myxoid tissue
through an incomplete capsule (►Fig. 6). The lesion enhances
moderately, which is predominantly centrally located, result-
ing in a smokelike appearance38(►Fig. 6).
Nodular Fasciitis
Nodular fasciitis is a benign soft tissue lesion composed of
fibroblastic-myofibroblastic cells that may involve the shoul-
der and upper arm.3 Based on the location, the three main

Fig. 14 Lipoblastoma in an 11-year-old girl. (a) Axial T1-WI, (b) axial, and (c) coronal fat-suppressed T1-WI after administration of gadolinium
contrast show a well-delineated retroclavicular fatty mass. The lesion is inhomogeneous with intralesional components showing enhancement.

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 Soft Tissue Tumors about the Shoulder
Fig. 15 Schwannoma. Note entering/exiting nerve (white arrows) on
longitudinal fat-suppressed T2-WI on the course of the ulnar nerve.
types of nodular fasciitis are subcutaneous, fascial, and
intramuscular. The subcutaneous and fascial type are more
common than the intramuscular type.
On US, the lesion is usually hypoechoic with mildly
increased Doppler flow.
The SI pattern on MRI reflects the histologic composition of
the lesion. Cellular parts are isointense to or slightly higher than
skeletal muscle on T1-WI and hyperintense to fat on T2-WI,
whereas fibrous areas are hypointense on all pulse sequences.26
Contrast enhancement is usually diffuse but may be predomi-
nantly peripheral as well (“inverted target sign”).39 Linear
extension along the fascia (“fascial tail sign”) may suggest the
diagnosis.38 There is often mild surrounding edema.33
Fig. 16 Ancient schwannoma. (a) Longitudinal ultrasound, (b) coronal fat-suppressed (FS) T2-WI, and (c) coronal FS T1-WI after administration of
gadolinium contrast show a well-delineated oval mass showing intralesional “cystic” areas that are anechogenic on ultrasound, hyperintense on
T2-WI, and do not show enhancement.
Vanhoenacker, Verstraete 295
Table 6 Imaging parameters in favor of a malignant peripheral
nerve sheath tumor
MPNST versus a benign neurogenic tumor
• Large size (> 5 cm)
• Mass effect and on adjacent structures
• Ill-defined margins
• Perilesional edema
• Fast heterogeneous enhancement
• Invasion of adjacent bony structures
• Involvement of regional lymph nodes
Abbreviation: MPNST, malignant peripheral nerve sheath tumor.
Desmoid Tumors (Desmoid-type Fibromatosis)
Desmoid-type fibromatosis, formerly known as desmoid or
aggressive fibromatosis, is a neoplastic disorder of fibroblas-
tic tissue of intermediate grade. It arises from connective
tissue or its overlying aponeurosis or fascia.40 The deltoid
muscle region is a site of predilection.
On US, desmoid tumors appear ill defined, mainly seen as
solid hypoechoic masses. If large, the tumor may cause
prominent posterior acoustic shadowing, probably due to
the large amount of intralesional collagen.40 Peripheral neo-
vascularity may be seen as well.
On MRI, desmoid tumors are isointense or mild hyperintense
on T1-WI. Heterogeneity on T2-WI or fluid-sensitive sequences
is the rule. Areas of low signal correspond to collagen extending
along fascial planes and do not enhance after contrast agent
administration. Areas of high SI, representing more cellular
components, show more prominent enhancement.40,41 Tumor
heterogeneity and the irregular infiltrative nature of the lesion
may mimic malignancy. The clues to the correct diagnosis are the
location around the fascial planes and the presence of areas of
low signal areas on T2-WI (►Fig. 7).
Malignant Tumors
Malignant STTs about the shoulder comprise a heterogeneous
group of tumors (►Table 2). They are most often seen in
middle-aged or elderly patients, although fibrosarcoma,
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296 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete

Fig. 17 Large plexiform neurofibroma in the right upper arm in a patient with neurofibromatosis type I. (a) Axial T1-WI of the right upper arm
shows a large multilobular intramuscular mass in the anterior compartment of the right upper arm. The mass is isointense to muscle surrounded
by a peripheral rim of fat (white arrows). (b) Coronal fat-suppressed T1-WI after gadolinium contrast shows a large branching mass with
heterogeneous enhancement.

rhabdomyosarcoma, and hemangiosarcoma should be kept in
mind in children < 5 years of age.2 In adolescents and young
adults, synovial cell sarcoma should be included in the
differential diagnosis.2 In adult patients, myxofibrosarcoma
(►Figs. 4 and 19) and liposarcoma are most prevalent.2 MRI
visualizes intralesional macroscopic tissue components of the
tumor (such as fatty components in liposarcoma, intrale-
sional bleeding in high-grade sarcomas, myxoid tissue in
myxoid liposarcoma, and myxofibrosarcoma) and vasculari-
zation of the lesion. In this regard, potential imaging charac-
terization of malignant STTs containing fat or myxoid tissue
(►Fig. 19) is possible. Because MRI of other malignant STTs is
mostly nonspecific, tissue-specific diagnosis based on imag-
ing alone is often illusive.6,10
The main task of the radiologist, however, is to
make the differential diagnosis between benign and poten-
tially malignant lesions (►Table 4) and to refer patients
with potentially malignant lesions to centers with
special expertise in the diagnosis and management of
STTs (►Figs. 19 and 20).
Further detailed description of different histologic types is
beyond the scope of this article. Textbooks1,4,33 and dedicated
articles on those specific phenotypes of tumors are valuable
resources.42
Intramuscular soft tissue metastases should be considered
in case of a known malignancy and if multiple lesions are
seen. The presence of a solitary lesion, however, does not
exclude malignancy43(►Fig. 21).

Fig. 18 Intramuscular low-flow vascular malformation in the right upper arm. (a) Coronal fat-suppressed (FS) T2-WI an intramuscular mass within
the triceps. The mass is of high signal and has multilobular appearance (“bunch of grapes”). Note adjacent vessel at the cranial aspect of the lesion
(white arrow). (b) Axial FS T1-WI after gadolinium contrast shows marked heterogeneous enhancement.

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 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete 297

Fig. 19 Myxofibrosarcoma. (a) Axial and (b) coronal fat-suppressed (FS) T2-WI showing a large inhomogeneous lesion causing invasion of the left
acromioclavicular joint. The presence of large areas of high signal intensity are in favor of a myxoid-containing tumor. (c) Axial FS T1-WI after
gadolinium contrast shows marked inhomogeneous enhancement of the soft tissue lesion, lateral clavicle, and acromion.

Most metastases have nonspecific features on imaging, Conclusion

except for metastases of osteosarcoma (intralesional ossifica-
tion) and melanoma (increased SI on T1-WI due to melanin).
Soft tissue metastases often show areas of relatively low to
intermediate signal on T2-WI, owing to hypercellularity and
the increased nuclear-to-cytoplasmic ratio. Intralesional ne-
crosis and perilesional soft tissue edema are also common
features.44
STTs often involve the shoulder girdle. After considering the
age of the patient, meticulous analysis of imaging features
further aids in grading and characterization of STTs.
Generally, imaging analysis of soft tissue lesions about the
shoulder is not different from other areas of the body. MRI is
the preferred imaging technique.

Fig. 20 Leiomyosarcoma of the left upper arm. (a) Axial T1-WI, (b) axial fat-suppressed T2-WI, (c) axial T1-WI after gadolinium contrast show an
irregularly delineated intramuscular lesion with heterogeneous signal on all pulse sequences and heterogeneous enhancement (white arrows).
(d) Dynamic enhancement MRI shows rapid enhancement of the lesion with a steep slope on the time Intensity curve (arrows). These MR features
are very suspicious for a potential malignant soft tissue tumor that should be further examined by biopsy.

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298 Soft Tissue Tumors about the Shoulder Vanhoenacker, Verstraete

Fig. 21 Solitary intramuscular metastasis of a patient with a known renal cell carcinoma. (a) Axial T1-WI. (b) Axial T2-WI. (c) Sagittal fat-
suppressed (FS) T2-WI. Heterogeneous intramuscular lesion (white arrows) contains intralesional areas of relatively low signal on both pulse
sequences. Note also perilesional soft tissue edema on the sagittal T2-WI (white arrowheads). (d) Axial FS T1-WI after gadolinium contrast shows
heterogeneous enhancement.

In addition to the evaluation of the lesion’s extent, a major
role for imaging is to select those lesions that should undergo
biopsy. To ensure optimal diagnostic and therapeutic man-
agement, patients with aggressive and potentially malignant
lesions should be discussed at multidisciplinary meetings and
ideally referred to centers with extensive experience in the
diagnosis and treatment of malignant STTs.
Acknowledgment
The authors thank Natascha Van Roy for her assistance in
the preparation of this manuscript.
References
1 Fletcher CDM, Bridge JA, Hogendoorn P, Mertens F. World Health
Organization Classification of Tumours of Soft tissue and Bone. 4th
ed. Geneva, Switzerland: IARC Press; 2013
2 Kransdorf MJ. Malignant soft-tissue tumors in a large referral
population: distribution of diagnoses by age, sex, and location.
AJR Am J Roentgenol 1995;164(1):129–134
3 Kransdorf MJ. Benign soft-tissue tumors in a large referral popu-
lation: distribution of specific diagnoses by age, sex, and location.
AJR Am J Roentgenol 1995;164(2):395–402
4 De Schepper AM, Vanhoenacker F, Gielen J, Parizel P, eds. Imaging of
Soft Tissue Tumors. 3rd ed. Berlin, Germany: Springer-Verlag; 2006
5 De Schepper AM, Bloem JL. Soft tissue tumors: grading, staging,
and tissue-specific diagnosis. Top Magn Reson Imaging 2007;
18(6):431–444
6 Gielen JL, De Schepper AM, Vanhoenacker F, et al. Accuracy of MRI
in characterization of soft tissue tumors and tumor-like lesions. A
prospective study in 548 patients. Eur Radiol 2004;14(12):
2320–2330
7 van Rijswijk CS, Geirnaerdt MJ, Hogendoorn PCW, et al. Soft-tissue
tumors: value of static and dynamic gadopentetate dimeglumine-
enhanced MR imaging in prediction of malignancy. Radiology
2004;233(2):493–502
8 Sen J, Agarwal S, Singh S, Sen R, Goel S. Benign vs malignant soft
tissue neoplasms: limitations of magnetic resonance imaging.
Indian J Cancer 2010;47(3):280–286

Seminars in Musculoskeletal Radiology Vol. 19 No. 3/2015

 Soft Tissue Tumors about the Shoulder
9 Sundaram M. MR imaging of soft tissue tumors: an overview.
Semin Musculoskelet Radiol 1999;3(1):15–20
10 Vanhoenacker FM, Van Looveren K, Trap K, et al. Grading and
characterization of soft tissue tumors on magnetic resonance
imaging: the value of an expert second opinion report. Insights
Imaging 2012;3(2):131–138
11 Fayad LM, Jacobs MA, Wang X, Carrino JA, Bluemke DA. Musculo-
skeletal tumors: how to use anatomic, functional, and metabolic
MR techniques. Radiology 2012;265(2):340–356
12 Sandberg AA. Cytogenetics and molecular genetics in soft tissue
tumors. In: De Schepper AM, Vanhoenacker F, Gielen J, Parizel P,
eds. Imaging of Soft Tissue Tumors. 3rd ed. Berlin, Germany:
Springer-Verlag; 2006:93–106
13 Buchbender C, Heusner TA, Lauenstein TC, Bockisch A, Antoch G.
Oncologic PET/MRI, part 2: bone tumors, soft-tissue
tumors, melanoma, and lymphoma. J Nucl Med 2012;53(8):
1244–1252
14 Anderson MW, Temple HT, Dussault RG, Kaplan PA. Compartmen-
tal anatomy: relevance to staging and biopsy of musculoskeletal
tumors. AJR Am J Roentgenol 1999;173(6):1663–1671
15 Vanhoenacker FM, Van der Woude HJ, Vanhoenacker PK, De
Praeter G. MR arthrography of the rotator cuff. JBR-BTR 2007;
90(5):338–344
16 Vanhoenacker FM, Mespreuve MF, De Schepper AM, Cornelis S.
Images in clinical radiology. The geyser phenomenon in a long-
standing rotator cuff tear. JBR-BTR 2001;84(4):167
17 Ken O, Hatori M, Kokubun S. The MRI features and treatment of
scapulothoracic bursitis: report of four cases. Ups J Med Sci 2004;
109(1):57–64
18 Vancamp E, Vanhoenacker F, Bernard P, Bosmans JL, Verstraete KL.
Swelling subscapularis with specific characteristics for imaging.
Ortho-Rheumatol 2013;11(5):16–18
19 Ardies L, De Beule T, Degroote T, Vanhoenacker FM, Vanhoenacker
PK. Bilateral intramuscular pseudotumor in a bodybuilder. JBR-
BTR 2012;95(2):108
20 Schultzel MM, Johnson MH, Rosenthal HG. Bilateral deltoid myo-
sitis ossificans in a weightlifter using anabolic steroids. Orthope-
dics 2014;37(9):e844–e847
21 Kir MC, Ozdemir MT. Myositis ossificans around shoulder follow-
ing military training programme. Indian J Orthop 2011;45(6):
573–575
22 Tyler P, Saifuddin A. The imaging of myositis ossificans. Semin
Musculoskelet Radiol 2010;14(2):201–216
23 Wang XL, Malghem J, Parizel PM, Gielen JL, Vanhoenacker F, De
Schepper AM. Pictorial essay. Myositis ossificans circumscripta.
JBR-BTR 2003;86(5):278–285
24 Bashir WA, O’Donnell P. The myositides: the role of imaging in
diagnosis and treatment. Semin Musculoskelet Radiol 2010;14(2):
217–226
25 Vanhoenacker F, Vanwambeke K, Bosmans J. Pseudotumeur inflam-
matoire de la ceinture scapulaire. Ortho-rhumato 2010;8:13–14
26 Walker EA, Salesky JS, Fenton ME, Murphey MD. Magnetic reso-
nance imaging of malignant soft tissue neoplasms in the adult.
Radiol Clin North Am 2011;49(6):1219–1234
27 Toirkens J, De Schepper AM, Vanhoenacker F, et al. A comparison
between histopathology and findings on magnetic resonance
View publication stats
Vanhoenacker, Verstraete 299
imaging of subcutaneous lipomatous soft-tissue tumors. Insights
Imaging 2011;2(5):599–607
28 Kransdorf MJ, Bancroft LW, Peterson JJ, Murphey MD, Foster WC,
Temple HT. Imaging of fatty tumors: distinction of lipoma and
well-differentiated liposarcoma. Radiology 2002;224(1):
99–104
29 Reiseter T, Nordshus T, Borthne A, Roald B, Naess P, Schistad O.
Lipoblastoma: MRI appearances of a rare paediatric soft tissue
tumour. Pediatr Radiol 1999;29(7):542–545
30 Daineffe S, Vandevenne J, Palmers Y. Retroscapular hibernoma.
JBR-BTR 2005;88(3):118–119
31 Liu W, Bui MM, Cheong D, Caracciolo JT. Hibernoma: comparing
imaging appearance with more commonly encountered benign or
low-grade lipomatous neoplasms. Skeletal Radiol 2013;42(8):
1073–1078
32 De Schepper AM, Vanhoenacker FM. Soft tissue tumors. In: Pope
T, Bloem HJ, Beltran J, Morisson WB, Wilson DJ, eds. Imaging of
Soft Tissue Tumors. 2nd ed. Berlin, Germany: Saunders; 2015:
970–995
33 Kransdorf MJ, Murphey MD. Imaging of Soft Tissue Tumors. 2nd
ed. Philadelphia, PA: Lippincott Williams Wilkins; 2006
34 Woertler K. Tumors and tumor-like lesions of peripheral nerves.
Semin Musculoskelet Radiol 2010;14(5):547–558
35 Simoens WA, Wuyts FL, De Beuckeleer LH, Vandevenne JE, Bloem
JL, De Schepper AM. MR features of peripheral nerve sheath
tumors: can a calculated index compete with radiologist’s experi-
ence? Eur Radiol 2001;11(2):250–257
36 Flors L, Leiva-Salinas C, Maged IM, et al. MR imaging of soft-tissue
vascular malformations: diagnosis, classification, and therapy follow-
up. Radiographics 2011;31(5):1321–1340; discussion 1340–1341
37 Kim TK, Lee DH, Park JH, Kim CH, Jeong WK. Synovial osteo-
chondromatosis in the subacromial bursa mimicking calcific
tendinitis: sonographic diagnosis. J Clin Ultrasound 2014;42(4):
237–240
38 Peterson KK, Renfrew DL, Feddersen RM, Buckwalter JA, el-Khoury
GY. Magnetic resonance imaging of myxoid containing tumors.
Skeletal Radiol 1991;20(4):245–250
39 Wang XL, De Schepper AM, Vanhoenacker F, et al. Nodular fasciitis:
correlation of MRI findings and histopathology. Skeletal Radiol
2002;31(3):155–161
40 Chew NS, Vanhoenacker FM. Aggressive fibromatosis: is PET-
CT useful in lesion characterization? JBR-BTR 2013;96(5):
301–303
41 Walker EA, Petscavage JM, Brian PL, Logie CI, Montini KM, Mur-
phey MD. Imaging features of superficial and deep fibromatoses in
the adult population. Sarcoma 2012;2012:215810
42 Walker EA, Salesky JS, Fenton ME, Murphey MD. Magnetic reso-
nance imaging of malignant soft tissue neoplasms in the adult.
Radiol Clin North Am 2011;49(6):1219–1234, vi
43 Glockner JF, White LM, Sundaram M, McDonald DJ. Unsuspected
metastases presenting as solitary soft tissue lesions: a fourteen-
year review. Skeletal Radiol 2000;29(5):270–274
44 De Schepper A, Khan S, Alexia J, De Beuckeleer L. Soft tissue
metastasis. In: De Schepper AM, Vanhoenacker F, Gielen J, Parizel
P, eds. Imaging of Soft Tissue Tumors. 3rd ed. Berlin, Germany:
Springer-Verlag; 2006:447–460
Seminars in Musculoskeletal Radiology Vol. 19 No. 3/2015