Soft tissue sarcomas or intramuscular haematomas?

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Abstract

Haematomas are common and sarcomas are rare. However the absence of trauma or a light trauma should alert the clinician to the possibility that the abnormality may represent haemorrhage into a tumor and not just haematoma, even in a haemophilic patient. Clinical findings, sonography with Doppler assessment and magnetic resonance images with contrast administration will help in the differential diagnosis. The diagnosis of a high grade sarcoma must be considered in these patients and any doubt should be resolved with a biopsy to avoid tragic consequences of missed sarcoma.

Introduction

The incidence of soft tissue sarcoma represents approximately 1% of all malignancies [1]. Soft tissue sarcomas are a heterogeneous group of tumors that arise from tissue of mesenchymal origin and are characterized by infiltrative local growth [1], [2]. The metastatic spread of sarcomas is mainly haematogenous to the lungs, although lymphatic spread may occur. Soft tissue sarcomas can occur at any site throughout the body. Almost 45% of all soft tissue sarcomas are found in the extremities, especially in the lower limb [1]. The consequences of a missed case of sarcoma are serious; even a low grade sarcoma may metastasise. Spontaneous intramuscular haematomas in the extremities are very rare and should be approached with a high degree of clinical suspicion even if chronic expanding spontaneous haematoma have been described previously [3], [4].

Section snippets

Clinical findings

The patients present themselves with a soft tissue mass of which it is necessary to specify the circumstances of appearance. Sarcomas appear spontaneously, grow slowly without pain in the beginning in most of cases [1], [5]. Haematomas appear in specific context: after trauma or a bleeding disorder, grow in few hours and are painful. There are 3 pitfalls: in some cases of sarcomas a history of trauma is reported by patients, spontaneous haematoma could reveal high grade sarcomas, and

Imaging findings

After physical examination, a sonography will be performed in most cases. The aim of sonography [10] is to differentiate a pure cystic lesion from a partial cystic or a solid lesion. In case of pure cystic lesion, its origin must be found: aneurysm, popliteal cysts. Some solid lesions are also typical: lymph nodes, superficial lipoma. In all other cases Doppler sonography must be performed to find abnormal vessels inside mass.

If all elements are corroborating (Fig. 1), type of trauma, size of

Conclusion

Differential diagnosis between malignant and benign soft tissue lesions has proven to be a difficult task even with the advantage of MRI [14], [15]. But in following previous describe imaging protocol in front of non-spontaneous decrease haematoma without bleeding disorders, the risk to miss a solid tumor could be discard even if signs of solid tumor are subtle (Fig. 8).

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