Intraosseous Ganglion Cyst Mimicking Chondrosarcoma On MRI: A Case Report

Intraosseous Ganglion Cyst Mimicking Chondrosarcoma On MRI: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case report Intraosseous Ganglion Cyst Mimicking Chondrosarcoma On MRI: A Case Report Eunhye Seo, Yu Sung Yoon, Hee Kyung Kim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-605077/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Jan, 2022 Read the published version in European Journal of Medical Research → Version 1 posted 9 You are reading this latest preprint version Abstract Background The intraosseous ganglia is a benign cyst, rarely locate in the olecranon process. As intraosseous ganglia can mimic malignant bone tumor, computed tomography (CT) is improtant for diagnosis even when magnetic resonance imaging (MRI) suggests malignant bone tumor such as chondrosarcoma. Case presentation In this paper, we report a 42-year-old woman with intraosseous ganglia in the olecranon process of the ulna. She complained pain in right elbow for 3 weeks. MRI revealed an intraosseous mass which initially diagnosed as chondrosarcoma. However, followed computed tomography (CT) demonstrated scattered intralesional gas and no underlying mineralization, and we can exclude chondrosarcoma from diagnosis. Conclusions The intraosseous ganglia can mimic bone tumor in MRI, therefore CT is essential for accurate characterization of bone tumor. Even if MR imaging strongly suggests chondrosarcoma of the bone, CT should be performed as additional study. Internal Medicine Olecranon process Intraosseous ganglia Chondrosarcoma Magnetic resonance imaging Computed tomography Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Intraosseous ganglia are benign cystic lesions consisting of fibrous tissue with extensive mucoid degeneration ( 1 ). These cysts occur less frequently in the upper extremities and olecranon involvement is extremely rare ( 1 , 2 ). It can also cause pain ( 1 – 3 ). We report a case of intraosseous ganglia in the olecranon process of the ulna, which was initially interpreted as chondrosarcoma with high signal intensity (SI) on T2-weighted fat-suppressed imaging, intermediate SI on T1-weighted imaging, and peripheral lobular enhancement. The patient also exhibited perilesional bone marrow edema, cortical breach, and extraosseous extension, which are common with malignant bone tumors ( 4 ). However, a final radiologic diagnosis of intraosseous ganglia was reached based on CT before surgery, because scattered gas was observed within the presumed tumor, suggesting endogenous causes such as possession of cavity means hypocellularity and negative pressure due to juxtaarticular location. Its unusual location and MRI findings of intraosseous ganglia mimicking a chondrosarcoma were interesting and informative. Case Presentation A 42-year-old woman presented to the outpatient clinic with continuous pain in her right elbow that started 3 weeks prior. She had previously undergone conservative physical therapy at another hospital, but her symptoms were not relieved. The patient reported a Numeric Rating Scale (NRS-11) score of 2 ( 5 ). She had no recent history of trauma or elbow injury, and had no complaints of fever, local heat, or pain in other joints. On physical examination, there was no tenderness, swelling, range of motion limitation, nor external wound on the right elbow. The patient had no other relevant medical history or abnormal laboratory findings. Plain radiographs of her right elbow joint demonstrated an osteolytic bone lesion 2.0 cm in extent in the olecranon process (Fig. 1 ). Contrast enhanced MRI was performed using a 3.0-T MRI scanner (Magnetom Skyra, Siemens, Germany). MRI revealed an approximately 1.5x1.3x2.3-cm-sized intraosseous mass with marginal lobulation, peripheral lobular enhancement with a regional enhancing portion, and prominent endosteal scalloping. Also, the lesion had a focal cortical breach with extraosseous extension and perilesional bone marrow edema. There was no definite evidence of joint involvement (Fig. 2 – 4 ). CT was performed to clarify the underlying mineralization. On CT, no underlying osteoid or chondroid mineralization was observed except thin septa suggesting hyperdense structure (Fig. 5 ). The mass was surgically removed by curettage and elbow pain was relieved after surgery. Pathologic examination of the specimen revealed fragments of fibrous membranous tissue with mucoid degeneration and no epithelial lining (Fig. 6 ). Discussion Ganglion cysts are fluid-filled lumps that typically develop in the soft tissue along tendons and joints ( 6 , 7 ). Intraosseous ganglia are rare and commonly located in the tibia, fibula, humerus, ulna, radius, carpal and tarsal bones, acetabulum, and scapular bone ( 1 , 8 – 11 ). The pathophysiology of intraosseous ganglia remains unclear, but it has been suggested that mechanical stress or trauma, synovial herniation, mucoid degeneration, and intramedullary metaplasia of mesenchymal cells may be the main causes ( 1 , 12 , 13 ). Gas within the bone can be seen under various conditions such as emphysematous osteomyelitis, pneumatocyst, osteonecrosis, and postoperative emphysema ( 14 ). The gas results from gas-forming pathogens, exogenous air, and nitrogen gas from soft tissue due to distraction induced negative pressure ( 14 , 15 ). In negative-pressure related cases, some lesions have been reported in near completely normal joints without evidence of degenerative changes or a clear connection to the joint space ( 14 ). Maldague et al. ( 16 ) believed that the presence of gas in a fracture was due to a lack of tissue, fluid and blood. Likewise, gas within bone tumors suggests a cellular paucity, indicating that reabsorption of gas to surrounding tissues does not occur easily or well liberating environment of nitrogen gas ( 1 , 17 ). In our case, a lack of tissue with mucoid content in the intraosseous ganglia may have contributed to the development of negative pressure, and the juxtaarticular location was also affected by negative pressure due to joint movement and maintenance. That negative pressure can result in a decrease in gas solubility. There was adjacent subcortical sclerosis and articular surface irregularities, but no clear connection was observed in CT and MRI. Gas collection was only identified on CT. According to previous literature, gas in the vertebra or intervertebral discs, and formation of gas due to infection can be excluded if there is no evidence of concomitant infection such as osteomyelitis or paravertebral soft tissue lesions ( 15 ). To the best of our knowledge, no malignant bone tumors with air in the lesion have been reported in the English literature. It is believed that the high-density tissue of malignant tumors contributes to gas reabsorption. In our case, the reasons for a diagnosis of chondrosarcoma based on MRI were as follows: greater than two-thirds endosteal scalloping of the normal cortical thickness, a peripheral lobular enhancing pattern, cortical breach, and an enhancing solid extraosseous component. These findings strongly suggest chondrosarcoma ( 4 ). Even on retrospective MRI review, air was not clearly defined. CT is optimal diagnostic method for intraosseous ganglia because it can accurately illustrate underlying mineralization and even small amounts of gas ( 14 , 18 ). Conclusion A final radiologic diagnosis of intraosseous ganglion cyst was reached with CT before surgery based on scattered gas within the lesion. Intraosseous ganglion cysts can mimic bone tumors on MRI; therefore, CT is essential for accurate characterization of bone lesions and differentiation of intraosseous ganglia from chondrosarcoma. Abbreviations CT =computed tomography, MRI = magnetic resonance imaging, SI = signal intensity Declarations Ethics approval and consent to participate The case report was approved and supervised by the ethics committee of the Soonchunhyang University Bucheon Hospital (committee’s reference number; 2021-04-014). Consent for publication Informed consent was obtained from the patient. Availability of data and materials Not applicable Competing interests The authors declare that they have no competing interest Funding Supported by the Soonchunhyang University Research Fund. Authors' contributions Guarantors of integrity of entire study, Y.S.Y.; study concepts/study design or data acquisition or data analysis/interpretation, E.H.S., Y.S.Y., H.K.K.; manuscript drafting or manuscript revision for important intellectual content, E.H.S , Y.S.Y; approval of final version of submitted manuscript, all authors; agreement to ensure any questions related to the work are appropriately resolved, all authors; literature research, E.H.S.; and manuscript editing, Y.S.Y. Acknowledgements Not applicable References Ehara S, Kattapuram SV, Khurana JS, Rosenberg AE. Case-Report 551 - Intraosseous Ganglion of Olecranon with Vacuum Phenomenon. Skeletal Radiol. 1989;18(4):329–30. Zarezadeh A, Nourbakhsh M, Shemshaki H, Etemadifar MR, Mazoochian F. Intraosseous Ganglion Cyst of Olecranon. Int J Preventive Med. 2012;3(8):581–4. Kovarik J, Drac P. Symptomatic Intraosseous Ganglion of the Trapezium. Case Report and Literature Review. Acta Chir Orthop Tr. 2016;83(4):279–82. Murphey MD, Walker EA, Wilson AJ, Kransdorf MJ, Temple HT, Gannon FH. Imaging of primary chondrosarcoma: Radiologic-pathologic correlation. Radiographics. 2003;23(5):1245–78. Hartrick CT, Kovan JP, Shapiro S. The numeric rating scale for clinical pain measurement: a ratio measure? Pain Pract. 2003;3(4):310–6. Oshima J, Imai Y, Sasaki K, Sekido M. Giant Ganglion Cyst Arising from Iliac Wing, an Atypical Site. Indian J Plast Surg. 2021. Chatt N, Francois A, Acid S, Vande Berg B, Kirchgesner T. Giant intraosseous ganglion of the fibula: multimodality imaging. Skeletal Radiol. 2020;49(12):2063–7. Maeba T, Kahara N. Intraosseous Ganglion Cyst of the Sternoclavicular Joint. Prs-Glob Open. 2020;8(3). Crabbe W. Intra-osseous ganglia of bone. Br J Surg. 1966;53(1):15–7. Schajowicz F, Clavel Sainz M, Slullitel JA. Juxta-articular bone cysts (intra-osseous ganglia): a clinicopathological study of eighty-eight cases. The Journal of bone joint surgery British volume. 1979;61(1):107–16. Coulier B, Devyver B, Hamels J. Imaging demonstration of fistulous gas communication between joint and ganglion of medial malleolus. Skeletal Radiol. 2002;31(1):57–60. Sbai MA, Benzarti S, Boussen M, Msek H, Maalla R. Intraosseous ganglion cyst of the lunate: A case report. Chin J Traumatol. 2016;19(3):182–4. Bennett DC, Hauck RM. Intraosseous ganglion of the lunate. Ann Plas Surg. 2002;48(4):439–42. Al-Tarawneh E, Al-Qudah M, Hadidi F, Jubouri S, Hadidy A. Incidental intraosseous pneumatocyst with gas-density-fluid level in an adolescent: a case report and review of the literature. J Radiol Case Rep. 2014;8(3):16–22. Bielecki DK, Sartoris D, Resnick D, Van Lom K, Fierer J, Haghighi P. Intraosseous and intradiscal gas in association with spinal infection: report of three cases. AJR Am J Roentgenol. 1986;147(1):83–6. Maldague BE, Noel HM, Malghem JJ. The intravertebral vacuum cleft: a sign of ischemic vertebral collapse. Radiology. 1978;129(1):23–9. Sander R. Compilation of Henry's law constants (version 4.0) for water as solvent. Atmos Chem Phys. 2015;15(8):4399–981. Fitzek S, Engelmann C, Fitzek C. Vertebral Pneumatization. Clin Neuroradiol. 2011;21(1):27–30. Cite Share Download PDF Status: Published Journal Publication published 13 Jan, 2022 Read the published version in European Journal of Medical Research → Version 1 posted Editorial decision: Minor revision 04 Oct, 2021 Review # 1 received at journal 19 Aug, 2021 Reviews received at journal 15 Aug, 2021 Reviewer # 1 agreed at journal 14 Aug, 2021 Reviewers invited by journal 08 Aug, 2021 Editor assigned by journal 15 Jun, 2021 Submission checks completed at journal 15 Jun, 2021 Editor invited by journal 15 Jun, 2021 First submitted to journal 08 Jun, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-605077","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case report","associatedPublications":[],"authors":[{"id":34664453,"identity":"f92807be-2d20-4852-b8b6-9f2076877b78","order_by":0,"name":"Eunhye Seo","email":"","orcid":"","institution":"Soonchunhyang University Hospital Bucheon","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eunhye","middleName":"","lastName":"Seo","suffix":""},{"id":34664454,"identity":"846cdd88-6eb9-481b-9548-0ec6a4b1e0e5","order_by":1,"name":"Yu Sung Yoon","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYDACZiBMqPhnxw/iJBQQq+XBmQPJkg0gLQZE2sP4sO0A44YDIDYxWuTbmR8bJJy5w2x8fnXihwcGDPL8Ygfwa2FsZjNOSKh4xmd24+1mCaDDDGfOTiDgKmYe5gMJZ5iZzW6c3QDSkmBwm4AWNpCWxDZmxs0zzm7+QZQWHqCWhMS2w4wb+Hu3EWeLBDObMdD7ackSN3i3WSQYSBD2i3z/4ceSPyps7Pj7z26+CWTI80sT0IJkH1ilBLHKQYD/ACmqR8EoGAWjYCQBAODGQvjPP12WAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-2349-5256","institution":"Soonchunhyang University Hospital Bucheon","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yu","middleName":"Sung","lastName":"Yoon","suffix":""},{"id":34664455,"identity":"0b2bc19b-c670-4051-8b4a-119b747c4559","order_by":2,"name":"Hee Kyung Kim","email":"","orcid":"","institution":"Soonchunhyang University Hospital Bucheon","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hee","middleName":"Kyung","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2021-06-09 10:33:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-605077/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-605077/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40001-022-00631-0","type":"published","date":"2022-01-13T07:44:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":10693744,"identity":"0bc0a6ba-bcb3-4ee1-a069-b51cbd2935df","added_by":"auto","created_at":"2021-06-23 13:56:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":150792,"visible":true,"origin":"","legend":"Right elbow radiograph (lateral projection).\nA partially ill-defined osteolytic lesion ~2.0 cm in extent (white arrow) in the olecranon of the right ulna without discernible underlying mineralization.\n","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-605077/v1/507863045b5bb550b2a1446b.png"},{"id":10693976,"identity":"5e8c7087-eeaf-40a6-851f-cdb85eff4490","added_by":"auto","created_at":"2021-06-23 13:59:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":461310,"visible":true,"origin":"","legend":"MRI of the right elbow.\nIn-phase axial T2-weighted (T2W) (a), water only T2W (b), and T1-weighted (T1W) fat-suppressed contrast enhanced (c) images show a 1.5x1.3x2.3 cm sized intraosseous lesion with endosteal scalloping and peripheral enhancement. The lesion extended through cortical breach (white arrowheads) with enhancing extraosseous component (white arrow).","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-605077/v1/05d4b050f2218c629b777ab9.png"},{"id":10693639,"identity":"9c19b8f8-430e-40b0-8352-68ecbe466044","added_by":"auto","created_at":"2021-06-23 13:53:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":596725,"visible":true,"origin":"","legend":"Coronal T2W fat-suppressed (a), T1W (b), and T1W fat-suppressed contrast-enhanced (c) images showed a mass with lobulated T2 high signal intensity containing a lobular enhancing periphery, which had subtle peritumoral bone marrow edema and enhancement (white arrows).","description":"","filename":"fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-605077/v1/34d1da35f59d97f47d2bd125.png"},{"id":10693741,"identity":"5fb044ad-6142-41c7-9429-ae614f3feff5","added_by":"auto","created_at":"2021-06-23 13:56:42","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":527680,"visible":true,"origin":"","legend":"Axial T2W DIXON (a), T1W fat-suppressed contrast-enhanced (b), high b-value (b=1000) diffusion-weighted (c), and ADC map (d) images demonstrated an inferior-side-dominant enhancing solid portion, which showed diffusion restriction on high b-value scan (average ADC value; 0.85, minimum ADC value; 0.62, maximum ADC value; 1.07)","description":"","filename":"fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-605077/v1/92716f021747921575e770db.png"},{"id":10693644,"identity":"4c7362c4-360c-4f55-a063-577a456d8da4","added_by":"auto","created_at":"2021-06-23 13:53:42","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":209871,"visible":true,"origin":"","legend":"Axial (a) and sagittal (b) CT scan revealed intralesional gas (white arrow) without evidence of underlying osteoid or chondroid mineralization. Vacuum phenomenon was observed in ulnotrochlear joint with subcortical sclerosis and articular surface dimpling (black arrowheads), but there is no continuation between joint and osteolytic bone lesion. ","description":"","filename":"fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-605077/v1/f8af719300600b6f6fa3c3a3.png"},{"id":10693743,"identity":"d1640a2e-5534-44db-9d30-d5ab8d3097b9","added_by":"auto","created_at":"2021-06-23 13:56:42","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":700734,"visible":true,"origin":"","legend":"Microscopic findings of the specimen revealed fragments of fibrous membranous tissue with mucoid degeneration and no epithelial lining (hematoxylin and eosin, ×40).","description":"","filename":"fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-605077/v1/4b52cde3d74271fdf0d730ed.png"},{"id":17274395,"identity":"9f55832e-bbe6-4fd8-ba6c-d94887d79f4d","added_by":"auto","created_at":"2022-01-13 07:44:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2250680,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-605077/v1/5842f041-90db-46d7-96cc-3bc48531e0dd.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eIntraosseous Ganglion Cyst Mimicking Chondrosarcoma On MRI: A Case Report\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eIntraosseous ganglia are benign cystic lesions consisting of fibrous tissue with extensive mucoid degeneration (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). These cysts occur less frequently in the upper extremities and olecranon involvement is extremely rare (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It can also cause pain (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe report a case of intraosseous ganglia in the olecranon process of the ulna, which was initially interpreted as chondrosarcoma with high signal intensity (SI) on T2-weighted fat-suppressed imaging, intermediate SI on T1-weighted imaging, and peripheral lobular enhancement. The patient also exhibited perilesional bone marrow edema, cortical breach, and extraosseous extension, which are common with malignant bone tumors (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, a final radiologic diagnosis of intraosseous ganglia was reached based on CT before surgery, because scattered gas was observed within the presumed tumor, suggesting endogenous causes such as possession of cavity means hypocellularity and negative pressure due to juxtaarticular location. Its unusual location and MRI findings of intraosseous ganglia mimicking a chondrosarcoma were interesting and informative.\u003c/p\u003e "},{"header":"Case Presentation","content":" \u003cp\u003eA 42-year-old woman presented to the outpatient clinic with continuous pain in her right elbow that started 3 weeks prior. She had previously undergone conservative physical therapy at another hospital, but her symptoms were not relieved. The patient reported a Numeric Rating Scale (NRS-11) score of 2 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). She had no recent history of trauma or elbow injury, and had no complaints of fever, local heat, or pain in other joints. On physical examination, there was no tenderness, swelling, range of motion limitation, nor external wound on the right elbow. The patient had no other relevant medical history or abnormal laboratory findings.\u003c/p\u003e \u003cp\u003ePlain radiographs of her right elbow joint demonstrated an osteolytic bone lesion 2.0 cm in extent in the olecranon process (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Contrast enhanced MRI was performed using a 3.0-T MRI scanner (Magnetom Skyra, Siemens, Germany). MRI revealed an approximately 1.5x1.3x2.3-cm-sized intraosseous mass with marginal lobulation, peripheral lobular enhancement with a regional enhancing portion, and prominent endosteal scalloping. Also, the lesion had a focal cortical breach with extraosseous extension and perilesional bone marrow edema. There was no definite evidence of joint involvement (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCT was performed to clarify the underlying mineralization. On CT, no underlying osteoid or chondroid mineralization was observed except thin septa suggesting hyperdense structure (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe mass was surgically removed by curettage and elbow pain was relieved after surgery. Pathologic examination of the specimen revealed fragments of fibrous membranous tissue with mucoid degeneration and no epithelial lining (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eGanglion cysts are fluid-filled lumps that typically develop in the soft tissue along tendons and joints (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Intraosseous ganglia are rare and commonly located in the tibia, fibula, humerus, ulna, radius, carpal and tarsal bones, acetabulum, and scapular bone (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The pathophysiology of intraosseous ganglia remains unclear, but it has been suggested that mechanical stress or trauma, synovial herniation, mucoid degeneration, and intramedullary metaplasia of mesenchymal cells may be the main causes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGas within the bone can be seen under various conditions such as emphysematous osteomyelitis, pneumatocyst, osteonecrosis, and postoperative emphysema (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The gas results from gas-forming pathogens, exogenous air, and nitrogen gas from soft tissue due to distraction induced negative pressure (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In negative-pressure related cases, some lesions have been reported in near completely normal joints without evidence of degenerative changes or a clear connection to the joint space (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Maldague et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) believed that the presence of gas in a fracture was due to a lack of tissue, fluid and blood. Likewise, gas within bone tumors suggests a cellular paucity, indicating that reabsorption of gas to surrounding tissues does not occur easily or well liberating environment of nitrogen gas (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In our case, a lack of tissue with mucoid content in the intraosseous ganglia may have contributed to the development of negative pressure, and the juxtaarticular location was also affected by negative pressure due to joint movement and maintenance. That negative pressure can result in a decrease in gas solubility. There was adjacent subcortical sclerosis and articular surface irregularities, but no clear connection was observed in CT and MRI. Gas collection was only identified on CT.\u003c/p\u003e \u003cp\u003eAccording to previous literature, gas in the vertebra or intervertebral discs, and formation of gas due to infection can be excluded if there is no evidence of concomitant infection such as osteomyelitis or paravertebral soft tissue lesions (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). To the best of our knowledge, no malignant bone tumors with air in the lesion have been reported in the English literature. It is believed that the high-density tissue of malignant tumors contributes to gas reabsorption. In our case, the reasons for a diagnosis of chondrosarcoma based on MRI were as follows: greater than two-thirds endosteal scalloping of the normal cortical thickness, a peripheral lobular enhancing pattern, cortical breach, and an enhancing solid extraosseous component. These findings strongly suggest chondrosarcoma (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Even on retrospective MRI review, air was not clearly defined. CT is optimal diagnostic method for intraosseous ganglia because it can accurately illustrate underlying mineralization and even small amounts of gas (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eA final radiologic diagnosis of intraosseous ganglion cyst was reached with CT before surgery based on scattered gas within the lesion. Intraosseous ganglion cysts can mimic bone tumors on MRI; therefore, CT is essential for accurate characterization of bone lesions and differentiation of intraosseous ganglia from chondrosarcoma.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cp\u003eCT =computed tomography, MRI\u0026thinsp;=\u0026thinsp;magnetic resonance imaging, SI\u0026thinsp;=\u0026thinsp;signal intensity\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe case report was approved and supervised by the ethics committee of the Soonchunhyang University Bucheon Hospital (committee\u0026rsquo;s reference number; 2021-04-014). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eSupported by the Soonchunhyang University Research Fund.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eGuarantors of integrity of entire study, Y.S.Y.; study concepts/study design or data acquisition or data analysis/interpretation, E.H.S., Y.S.Y., H.K.K.; manuscript drafting or manuscript revision for important intellectual content, E.H.S , Y.S.Y; approval of final version of submitted manuscript, all authors; agreement to ensure any questions related to the work are appropriately resolved, all authors; literature research, E.H.S.; and manuscript editing, Y.S.Y.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEhara S, Kattapuram SV, Khurana JS, Rosenberg AE. Case-Report 551 - Intraosseous Ganglion of Olecranon with Vacuum Phenomenon. Skeletal Radiol. 1989;18(4):329\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZarezadeh A, Nourbakhsh M, Shemshaki H, Etemadifar MR, Mazoochian F. Intraosseous Ganglion Cyst of Olecranon. Int J Preventive Med. 2012;3(8):581\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKovarik J, Drac P. Symptomatic Intraosseous Ganglion of the Trapezium. Case Report and Literature Review. Acta Chir Orthop Tr. 2016;83(4):279\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurphey MD, Walker EA, Wilson AJ, Kransdorf MJ, Temple HT, Gannon FH. Imaging of primary chondrosarcoma: Radiologic-pathologic correlation. Radiographics. 2003;23(5):1245\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHartrick CT, Kovan JP, Shapiro S. The numeric rating scale for clinical pain measurement: a ratio measure? Pain Pract. 2003;3(4):310\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOshima J, Imai Y, Sasaki K, Sekido M. Giant Ganglion Cyst Arising from Iliac Wing, an Atypical Site. Indian J Plast Surg. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChatt N, Francois A, Acid S, Vande Berg B, Kirchgesner T. Giant intraosseous ganglion of the fibula: multimodality imaging. Skeletal Radiol. 2020;49(12):2063\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaeba T, Kahara N. Intraosseous Ganglion Cyst of the Sternoclavicular Joint. Prs-Glob Open. 2020;8(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrabbe W. Intra-osseous ganglia of bone. Br J Surg. 1966;53(1):15\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchajowicz F, Clavel Sainz M, Slullitel JA. Juxta-articular bone cysts (intra-osseous ganglia): a clinicopathological study of eighty-eight cases. The Journal of bone joint surgery British volume. 1979;61(1):107\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoulier B, Devyver B, Hamels J. Imaging demonstration of fistulous gas communication between joint and ganglion of medial malleolus. Skeletal Radiol. 2002;31(1):57\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSbai MA, Benzarti S, Boussen M, Msek H, Maalla R. Intraosseous ganglion cyst of the lunate: A case report. Chin J Traumatol. 2016;19(3):182\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBennett DC, Hauck RM. Intraosseous ganglion of the lunate. Ann Plas Surg. 2002;48(4):439\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Tarawneh E, Al-Qudah M, Hadidi F, Jubouri S, Hadidy A. Incidental intraosseous pneumatocyst with gas-density-fluid level in an adolescent: a case report and review of the literature. J Radiol Case Rep. 2014;8(3):16\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBielecki DK, Sartoris D, Resnick D, Van Lom K, Fierer J, Haghighi P. Intraosseous and intradiscal gas in association with spinal infection: report of three cases. AJR Am J Roentgenol. 1986;147(1):83\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaldague BE, Noel HM, Malghem JJ. The intravertebral vacuum cleft: a sign of ischemic vertebral collapse. Radiology. 1978;129(1):23\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSander R. Compilation of Henry's law constants (version 4.0) for water as solvent. Atmos Chem Phys. 2015;15(8):4399\u0026ndash;981.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFitzek S, Engelmann C, Fitzek C. Vertebral Pneumatization. Clin Neuroradiol. 2011;21(1):27\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Olecranon process, Intraosseous ganglia, Chondrosarcoma, Magnetic resonance imaging, Computed tomography","lastPublishedDoi":"10.21203/rs.3.rs-605077/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-605077/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\u003cp\u003eThe intraosseous ganglia is a benign cyst, rarely locate in the olecranon process. As intraosseous ganglia can mimic malignant bone tumor, computed tomography (CT) is improtant for diagnosis even when magnetic resonance imaging (MRI) suggests malignant bone tumor such as chondrosarcoma.\u003c/p\u003e\u003cp\u003eCase presentation\u003c/p\u003e\u003cp\u003eIn this paper, we report a 42-year-old woman with intraosseous ganglia in the olecranon process of the ulna. She complained pain in right elbow for 3 weeks. MRI revealed an intraosseous mass which initially diagnosed as chondrosarcoma. However, followed computed tomography (CT) demonstrated scattered intralesional gas and no underlying mineralization, and we can exclude chondrosarcoma from diagnosis. \u003c/p\u003e\u003cp\u003eConclusions\u003c/p\u003e\u003cp\u003eThe intraosseous ganglia can mimic bone tumor in MRI, therefore CT is essential for accurate characterization of bone tumor. Even if MR imaging strongly suggests chondrosarcoma of the bone, CT should be performed as additional study.\u003c/p\u003e","manuscriptTitle":"Intraosseous Ganglion Cyst Mimicking Chondrosarcoma On MRI: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-06-23 13:53:40","doi":"10.21203/rs.3.rs-605077/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2021-10-05T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-08-20T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"editorInvitedReview","content":"","date":"2021-08-16T03:06:48+00:00","index":0,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-08-15T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-08-08T15:18:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-06-16T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-06-15T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-06-15T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Medical Research","date":"2021-06-08T19:16:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0b42012f-39c7-42d0-aa15-4f316d0a3eb6","owner":[],"postedDate":"June 23rd, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":5226057,"name":"Internal Medicine"}],"tags":[],"updatedAt":"2022-01-13T07:44:31+00:00","versionOfRecord":{"articleIdentity":"rs-605077","link":"https://doi.org/10.1186/s40001-022-00631-0","journal":{"identity":"european-journal-of-medical-research","isVorOnly":false,"title":"European Journal of Medical Research"},"publishedOn":"2022-01-13 07:44:31","publishedOnDateReadable":"January 13th, 2022"},"versionCreatedAt":"2021-06-23 13:53:40","video":"","vorDoi":"10.1186/s40001-022-00631-0","vorDoiUrl":"https://doi.org/10.1186/s40001-022-00631-0","workflowStages":[]},"version":"v1","identity":"rs-605077","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-605077","identity":"rs-605077","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}