ABSTRACT ID : IRIA 1149
BACKGROUND
 Pigmented Villonodular Synovitis (PVNS)- Benign proliferative disorder
that affects synovial lined joints, bursae, and tendon sheaths .
 PVNS is a slow-growing lesion of uncertain etiology arising from the
synovial membrane
 Two primary forms –
a) Diffuse form affects the entire synovial lining of a joint, bursa or
tendon sheath, involves the large joints.
B)Localized form - occurs around the tendon sheaths of small joints.
 The disease may show extraarticular soft tissue involvement, along with
a primary intraarticular process.
 PVNS involving the shoulder joint is uncommon and bilateral
involvement of shoulder is < 1 % cases.
 Common presentation in 3rd to 4th decade.
 It is usually monoarticular, polyarticular involvement is rare.
 Commonly involved joints- knee/ ankle/ hip/ finger joints.
 Shoulder joint involvement is extremely rare.
Two types:
 Diffuse - Affects the entire synovial lining of the joint, bursa, or
tendon, involves the large joints such as the knee and hip joints.
 Localized - Most common and involves small joints of the
hand/feet.
 The extra-articular form of PVNS is very rare and often
represents an extension of a primary intra-articular process.
CLINICAL FEATURES:
--Pain
of long duration/ Decreased range of motion/ Joint locking/
swelling of joint.
--Extra articular present with soft-tissue mass.
--Slight female predominance seen.
ETIOLOGY:
--Inflammatory process
--Repeated hemorrhage into the joint
--Repetitive mild trauma
--Neoplasia
--Disorder of lipid metabolism
 --Genetic rearrangement in both localized and diffuse types of
PVNS : chromosome 1p11-13, a site for CSF-1 gene, which most
commonly fuses to COL6a3 on chromosome 2q35.
CASE REPORTS
A 41 yr old female came with complaints of –
 Pain and swelling in both shoulders for past 5 months.
 Shoulder joint movement restriction since 5 months.
 Past history- No history of trauma.
 Not a known case of Tuberculosis/ Hypertension/ Diabetes mellitus.
 Previous CT imaging was done but images were not available.
 Family history- Not significant
EXAMINATION
GENERAL EXAMINATION:
- Afebrile, vitals stable
SYSTEMIC EXAMINATION:
OTHER SYSTEMSRS/ CVS/ CNS – No abnormality detected.
P/A- Soft.
LOCAL EXAMINATION:
-Inspection : Bilateral shoulder joint mild swelling.
Shoulder joint movement was restricted.
-Palpation: Bilateral warmth with tenderness present.
Bilateral shoulder joint soft – firm mobile masses .
Measurement- 5 x 4cm in right shoulder.
10 x 8cm in left shoulder.
CLINICAL DIAGNOSIS: ? Tubercular villonodular synovitis.
IMAGING
 PLAIN RADIOGRAPH of both the shoulder joints showing homogenous soft
tissue opacity infiltrating around the humerus.
 ULTRASOUND of both shoulder showing markedly thickened hypo echoic
synovium with nodular and villous projections with multiple heterogeneous
echogenic masses
RT

T1W
Cor
RT
T2W
Cor
RT
PDW
Cor
Gross distension of the sub acromial sub deltoid bursa (red arrows) which is filled with fluid and a large extra
articular multilobulated heterogeneous signal intensity lesion appearing low to intermediate signal intensity in
T1w images (green arrows) with variable signal intensity in T2w images (yellow arrows) within it, superior to
supraspinatus.
RT
T2 FFE
Cor
RT
 T2 FFE sequence showing few blooming artefacts (yellow arrow) signifying hemosiderin.
 Post contrast, the lesion shows intense contrast enhancement.
T1c + Gd
Cor
RT


PDW
Axial
RT
T1c + Gd
Cor
PDW sequence showing few similar signal intensity lesions in the intra-articular region (yellow arrows) and
supraspinatus muscle. Few bony lesions also noted (green arrow).
Post contrast sequence showing similar enhancement pattern as the extra-articular component.
 MRI PDW axial sequence showing few subchondral cystic
changes in the head of humerus (yellow arrow).
 Few lesions showing similar signal intensity and
enhancement pattern also seen in left head of humerus.
DIAGNOSIS
 Enhancing proliferative synovium with a lobulated mass in the
subacromial subdeltoid bursa
 Erosions in the humeral head with minimal involvement of the
shoulder joint and subscapularis muscle
 Features suggestive of extraarticular and intra articular form of
diffuse type of pigmented villonodular synovitis
DIFFERENTIAL DIAGNOSIS
 Primary synovial chondromatosis
--T2: high signal
--loose bodies formation
 Lipoma arborescens
--T2: high signal; will saturate on fat suppressed sequences
 Synovial sarcoma
--Mass around, but outside of, joint
--Frequently calcify
 Degenerative arthritis
--Joint space narrowing
--Subchondral sclerosis
CONCLUSION
 PVNS involvement of the shoulder joint is a rare location
with bilateral joints involved is uncommon.
 Findings of both intraarticular and extraarticular
involvement is a rare presentation
 The radiologic appearances of intraarticular PVNS,
particularly its MR imaging findings, are frequently
pathognomonic.
 MR imaging is the optimal modality to depict and define the
intraarticular and, particularly, extraarticular disease extent
in order to guide complete surgical excision
REFERENCES
 ChassaignacM. Cancer de la gaine des tendons. Gas Hosp Civ
Milit1852; 47: 185–190.
 JaffeHL, Lichtenstein L, Sutro CJ. Pigmented villonodular
synovitis, bursitis and tenosynovitis. Arch Pathol1941; 31: 731–765.
 WeissSW, Goldblum JR. Benign tumors and tumor-like lesions of
synovial tissue. In: Enzinger & Weiss’s soft tissue tumors.
Philadelphia, Pa: Mosby Elsevier, 2008; 769–788.
 KempsonRL, Fletcher CDM, Evans HL, Hendrickson MR, Sibley
RK. Synovial tumors. In: Atlas of tumor pathology: tumors of the
soft tissues. 3rd series. Washington, DC: Armed Forces Institute of
Pathology, 2001;138:387–394.
 KransdorfMJ, Murphey MD. Synovial tumors. In: Imaging of soft
tissue tumors. Philadelphia, Pa: Lippincott Williams &
Wilkins,2006; 381–436.