|Year : 2015 | Volume
| Issue : 1 | Page : 75-77
Fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography in evaluation of residual intramuscular myxoma
Anand Zade1, Archana Ahire2, Shishir Shetty3, Sujith Rai1, Rajashekharrao Bokka1, Arokiaswamy Velumani1, Rasika Kabnurkar4
1 Department of Molecular Imaging, Nueclear Healthcare Ltd., Kopar Khairane, Navi Mumbai, India
2 Department of Radiology, Jupiter Hospital, Thane, India
3 Department of Oncology, Fortis Hiranandani Hospital, Vashi, Navi Mumbai, India
4 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||23-Dec-2014|
Dr. Anand Zade
Department of Molecular Imaging, Nueclear Healthcare Ltd., Kopar Khairane, Navi Mumbai - 400 709, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Intramuscular myxoma (IM) is a rare benign neoplasm. In a patient diagnosed with IM of left thigh, we report the utility of a postoperative fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography scan in assessing the efficacy of surgical excision.
Keywords: Fluorine-18 fluorodeoxyglucose, intramuscular myxoma, positron emission tomography-computed tomography scan
|How to cite this article:|
Zade A, Ahire A, Shetty S, Rai S, Bokka R, Velumani A, Kabnurkar R. Fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography in evaluation of residual intramuscular myxoma. Indian J Nucl Med 2015;30:75-7
|How to cite this URL:|
Zade A, Ahire A, Shetty S, Rai S, Bokka R, Velumani A, Kabnurkar R. Fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography in evaluation of residual intramuscular myxoma. Indian J Nucl Med [serial online] 2015 [cited 2022 Aug 16];30:75-7. Available from: https://www.ijnm.in/text.asp?2015/30/1/75/147553
| Introduction|| |
Fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography (F-18 FDG PET-CT) has evolved as an imaging modality of choice for staging, restaging, treatment response evaluation and surveillance of various cancers. Increased FDG uptake is also noted in various benign conditions. Intramuscular myxoma (IM) is one such entity. Complete surgical excision is the treatment of choice with excellent prognosis. No recurrence is reported when the surgical excision is complete. However, recurrence has been documented in cases of incomplete surgical excision. We report a case where F-18 FDG PET-CT scan demonstrated residual disease in an operated case of IM.
| Case Report|| |
A 36-year-old male presented with slow growing painless lump in the left thigh. There was no history of trauma, fever, or weight loss. Other medical and family history was unremarkable.
Magnetic resonance imaging (MRI) of the thigh demonstrated a well-defined soft tissue lesion in the left rectus femoris muscle with homogenous low-signal intensity on T1-weighted sequences and markedly high signal intensity on T2-weighted sequences. Contrast-enhanced T1-weighted MRIs showed heterogeneous enhancement throughout the mass [Figure 1]. The differential diagnosis based on imaging findings was IM and myxoid liposarcoma. Excision of the mass was performed and on histopathological examination the tumor showed composition of spindle and stellate shaped cells that were widely separated by myxoid stroma. No pleomorphism, atypia, mitotic figures or necrosis was noted. The tumor cells were immunohistochemically positive for vimentin and CD34, but negative for S-100 and desmin. These findings were consistent with IM.  However, the cut margins were not free and the patient was referred 10 weeks later for F-18 FDG PET-CT scan for the assessment of residual disease. Increased F-18-FDG uptake was noted in the peripheral rim of a well-circumscribed centrally hypodense soft tissue lesion with thin septation in the left rectus femoris muscle [Figure 2]. The maximum standardized uptake value (SUVmax) of the lesion was 3.2 g/ml. These findings were suggestive of residual IM and the same was confirmed on histopathological examination of the postexcision specimen.
|Figure 1: Magnetic resonance imaging (MRI) of the thigh demonstrated a well-defined soft tissue lesion in the left rectus femoris muscle with homogenous low signal intensity on T1-weighted sequences (a) and markedly high signal intensity on T2-weighted sequences (b). Contrast-enhanced MRIs showed heterogeneous enhancement throughout the mass (c)|
Click here to view
|Figure 2: Increased fluorodeoxyglucose uptake was noted in the left upper thigh on maximum intensity projected (a), coronal positron emission tomography (PET) (b) and sagittal PET (e) images. This uptake corresponds to the peripheral rim of a well circumscribed centrally hypodense soft tissue lesion with thin septation in the left rectus femoris muscle on correlative coronal and sagittal computed tomography (CT) images (c and f) and PET-CT images (d and g), respectively|
Click here to view
| Discussion|| |
Intramuscular myxoma's are rare benign myxoid tumors. Most of them appear in the fourth to sixth decades of life with a slight female preponderance.  IM's usually arise from large skeletal muscles, the commonest location being the lower extremities, particularly the thigh (51%), followed by the gluteal region (7%). The symptoms depend on the site and size of the mass lesion. Although majority of the patients were asymptomatic and diagnosed incidentally, few present with slow growing, painless intramuscular tumor. Occasionally, the symptoms of nerve root compression may be noted. IM usually occurs as an isolated lesion, but sometimes it is associated with skeletal fibrous dysplasia, when it is known as Mazabraud's syndrome. In such cases, IM tends to be multifocal. 
Preoperatively, it is difficult to differentiate IM from other malignant myxoid tumors such as myxoid liposarcoma, low-grade fibromyxoid sarcoma, myxoid malignant fibrous histiocytoma and extra skeletal myxoid chondrosarcoma. On imaging, IM appears as hypoechoic mass on ultrasound, shows low attenuation on CT, low-signal intensity on T1-weighted MRIs, and markedly high signal intensity on T2-weighted MRIs. Contrast-enhanced imaging (particularly MRIs) more accurately reflects the truly solid (although usually hypocellular) consistency of the IM because it shows internal enhancement.
Several studies have been performed to evaluate the role of F-18 FDG PET-CT scan to differentiate benign and malignant myxoid neoplasms. However, the results were not encouraging. , The definite diagnosis of IM can only be made from the histopathological examination after its surgical excision, which is considered to be the treatment of choice. Complete resection is associated with excellent prognosis and no local recurrence generally occurs during an average follow-up of 7 years after excision. However, incomplete resection is associated with recurrence and completeness of surgery is the most important determinant of the overall outcome of the disease. 
There are four case reports demonstrating F-18-FDG uptake in IM. ,,, IM shows low-grade F-18 FDG uptake with SUV values between 1.3 and 2.6. Furthermore, whole body F-18 FDG PET-CT has been reported to be useful to detect fibrosis dysplasia and single or multiple IM's in Mazabraud's syndrome. However, its role in assessing postoperative residual IM is not described in the literature to the best of our knowledge. This case demonstrates the possible role of F-18 FDG PET-CT scan to detect postoperative residual IM.
| References|| |
Graadt van Roggen JF, Hogendoorn PC, Fletcher CD. Myxoid tumours of soft tissue. Histopathology 1999;35:291-312.
Murphey MD, McRae GA, Fanburg-Smith JC, Temple HT, Levine AM, Aboulafia AJ. Imaging of soft-tissue myxoma with emphasis on CT and MR and comparison of radiologic and pathologic findings. Radiology 2002;225:215-24.
Zoccali C, Teori G, Prencipe U, Erba F. Mazabraud's syndrome: A new case and review of the literature. Int Orthop 2009;33:605-10.
Feldman F, van Heertum R, Manos C. 18FDG PET scanning of benign and malignant musculoskeletal lesions. Skeletal Radiol 2003;32:201-8.
Aoki J, Watanabe H, Shinozaki T, Takagishi K, Tokunaga M, Koyama Y, et al.
FDG-PET for preoperative differential diagnosis between benign and malignant soft tissue masses. Skeletal Radiol 2003;32:133-8.
Nilgun O, Murat D, Baris O, Bilge G, Saban C, Nevzat D, et al
. Recurrent intramuscular myxoma: Review of the literature, diagnosis and treatment options. Turk J Cancer 2006;36:75-8.
Miyake M, Tateishi U, Maeda T, Arai Y, Seki K, Hasegawa T, et al.
F-18 fluorodeoxyglucose positron emission tomography finding of Mazabraud syndrome. Clin Nucl Med 2006;31:627-9.
Ho L, Wassef H, Henderson R, Seto J. F-18 fluorodeoxyglucose positron emission tomography/computed tomography imaging in left thigh intramuscular myxoma. Clin Nucl Med 2009;34:224-5.
Nishio J, Naito M. FDG PET/CT and MR imaging of intramuscular myxoma in the gluteus maximus. World J Surg Oncol 2012;10:132.
Singnurkar A, Phancao JP, Chatha DS, Stern J. The appearance of Mazabraud's syndrome on 18F-FDG PET/CT. Skeletal Radiol 2007;36:1085-9.
[Figure 1], [Figure 2]