This gentleman in his 40's, who is right hand dominant presented with a mass on the ulnar aspect of his right palm in the region of the pisiform. It does not feel like a ganglion.
Machine used: Philips IU22
Musculoskeletal Ultrasound report:
There is a well circumscribed, oval hypoechoic 9.4 x 5.1 x 10.5 mm mass (Figure 1), overlying the pisiform and ulnar nerve, but not overlying the ulnar artery, within the deep dermis and subcutaneous layer. Low level echoes within the mass are consistent with solid tissue, although there does appear to be a small cystic component, demonstrated by the posterior enhancement of sound. There is no visible communication between the mass, FCU, the nerve or the joint capsule. The tendons and nerve all appear normal, with no evidence of tenosynovitis. Colour Doppler demonstrated high vascularity (Figure 2 , 3 and 4), both peripherally and centrally. The blood pattern appears chaotic with multiple tortuous vessels visible. The feeding vessel is a branch of the ulnar artery. No cystic degeneration or calcifications were noted within the mass. The sonographic appearance is non-specific and could represent the following: haemangioma, vascular leiomyoma, eccrine spiradenoma, epithelial inclusion cyst.
The appearance is not typical for lipoma or neurofibroma. Synovial sarcoma is less likely, but cannot be excluded.
The final diagnosis was of a Angioleiomyoma. Angioleiomyoma is a benign tumour arising from the vascular smooth muscle (tunica media). This case provides a useful learning tool, as the sonographic findings of this case study such as the echogenicity, vascularity, mild posterior enhancement and lack of cystic degeneration were similar to the previous post of Schwannoma of the median nerve. However, both had very different outcomes at surgery.
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Many thanks to Bev Roos for providing this case study. Bev works at The Centre for Sports Medicine and Orthopaedics in Johannesburg, South Africa.