Is there any radiation-induced brachial plexopathy after hypofractionated postmastectomy radiotherapy with helical tomotherapy?

Introduction: Radiation-induced brachial plexopathy (RIBP) is one of the most concerning late radiation effects after hypofractionated postmastectomy radiotherapy (HF-PMRT) to the chest wall and regional lymph nodes. The purpose of this study was to investigate the RIBP events occurring in breast cancer patients after HF-PMRT using intensity-modulated radiation therapy (IMRT) by helical tomotherapy. Furthermore, the dosimetric parameters of the ipsilateral brachial plexus were reported. Materials and methods: Breast cancer patients who underwent HF-PMRT using the IMRT via HT at our institute were included. In the first cohort, subjective RIBP symptoms were measured using a QuickDASH questionnaire, whereas objective RIBP events were assessed using a comprehensive physical evaluation in the second cohort. The ipsilateral brachial plexus from all eligible patients' treatment plans was contoured, and the dosimetric parameters were explored. Results: From March 2014 to December 2022, 229 patients were enrolled; 107 and 72 individuals were in the first and second cohorts, respectively. The first cohort's median follow-up period was 27 months, and the second cohort was 31 months. In the first cohort, 80 patients (74.77%) had a normal function, 21 (19.63%) had a mild grade, and 6 (5.61%) had a moderate grade; no severe or very severe RIBP was observed. However, the comprehensive physical evaluation of the second cohort indicated no RIBP events. Dosimetric analysis revealed that the median maximum dose was 44.52, 44.52, and 44.60 Gy; the median mean dose was 33.00, 32.23, and 32.33 Gy; and the median dose at 0.03 cc was 44.33, 44.36, and 44.39 Gy for all patients, patients in the first and second cohort, respectively. Each dosimetric parameter was evaluated, and no statistically significant differences were detected. Conclusion: The absence of RIBP events supports the safety of employing HF-PMRT by HT for the chest wall and all regional lymph nodes. We propose that applying the ICRU Report 83 criteria for IMRT planning, which limit the maximum dose (107% of the prescribed dose) to less than 2% of the planning target volume and exclude the brachial plexus region from the maximal dose area, is a practical way to minimize the risk of RIBP from HF-PMRT.

Imaging of supra-thoracic tuberculosis.

Tuberculosis (TB) typically affects the lungs, but may involve many extra-pulmonary sites; with the latter especially prone in patients with human immunodeficiency virus infection. The clinical features of extra-pulmonary TB are often non-specific, mimicking many different disease entities. Application of the most appropriate imaging modality and knowing the imaging findings with clinical context awareness help initiation of further investigations, diagnosis and early treatment. This pictorial essay highlights the imaging spectrum of extra-pulmonary TB affecting the supra-thoracic region, i.e. brain, neck, and ear, nose and throat.

Can conventional magnetic resonance imaging at presentation predict chemoresistance in osteosarcoma?

OBJECTIVES: Histological tumour necrosis is the current indicator for the response of osteosarcoma after neoadjuvant chemotherapy. Chemoresistant tumours require close monitoring and adjustment of treatment. Characteristics of tumours on baseline MRI may be able to predict response to chemotherapy. The aim is to identify which baseline MRI findings can help predict chemoresistant osteosarcoma. METHODS: Baseline MRI before giving neoadjuvant chemotherapy of 95 patients during 2008-2021 was reviewed by 2 musculoskeletal radiologists. Histological necrosis from surgical specimens was the reference standard. MRIs were reviewed for tumour characteristics (tumour volume, maximum axial diameter, central necrosis, haemorrhage, fluid-fluid level), peritumoural bone and soft tissue oedema, and other parameters including intra-articular extension, epiphyseal involvement, neurovascular involvement, pathologic fracture, and skip metastasis. The cut-off thresholds were generated by receiver operating characteristic curves which then tested for diagnostic accuracy. RESULTS: Two-third of patients were chemoresistance (histological necrosis <90%). Tumour volume >150 mL, maximum axial diameter >7.0 cm, area of necrosis >50%, presence of intra-articular extension, and peritumoural soft tissue oedema >6.5 cm significantly predicted chemoresistance, particularly when found in combination. Tumour volume >150 mL and maximum axial diameter >7.0 cm could be used as an independent predictor (multivariable analysis, P-value = .025, .045). CONCLUSIONS: Findings on baseline MRI could help predicting chemoresistant osteosarcoma with tumour size being the strongest predictor. ADVANCES IN KNOWLEDGE: Osteosarcomas with large size, large cross-sectional diameter, large area of necrosis, presence of intra-articular extension, and extensive peritumoural soft tissue oedema were most likely to have a poor response to neoadjuvant chemotherapy.

Imaging of infra-thoracic tuberculosis.

Tuberculosis (TB) is a potentially curable disease that is a leading cause of death globally. While it typically affects the lungs, this disease may involve many extra-pulmonary sites, particularly in patients with risk factors. Extra-pulmonary TB often mimics a variety of different diseases, posing a diagnostic dilemma. Imaging aids in early diagnosis of TB, especially in patients with non-specific or atypical symptoms found at extra-pulmonary infra-thoracic locations. Imaging also helps guide appropriate laboratory investigation, monitor disease progress, and response to treatment. This review aims to highlight the imaging spectrum of TB affecting the infra-thoracic region, that is, gastrointestinal tract, abdominal lymph nodes, peritoneal cavity, intra-abdominal solid organs, and urogenital system.

Imaging of musculoskeletal tuberculosis.

Extra-pulmonary tuberculosis (TB) of the musculoskeletal system usually manifests with non-specific clinical features, mimicking a variety of diseases. Diagnosis and treatment of spinal and extra-spinal musculoskeletal TB are often challenging. Imaging has an important role in detecting this disease, aiding diagnosis, identifying complications, and monitoring disease progression. Radiographs and magnetic resonance imaging are the key imaging modalities utilized. Radiologists should aim to be familiar with the spectrum of imaging features of TB affecting spinal and extra-spinal locations in the musculoskeletal system.

Characterization of Cell-Free DNA Size Distribution in Osteosarcoma Patients.

PURPOSE: Cell-free DNA (cfDNA) analysis is a powerful tool for noninvasively predicting patient outcomes. We analyzed the size distribution of cfDNA and assessed its prognostic and diagnostic values in an osteosarcoma cohort. EXPERIMENTAL DESIGN: The fragment size distribution and level of cfDNA were analyzed in 15 healthy donors and 50 patients with osteosarcoma using automated capillary electrophoresis. The prognostic performance of cfDNA size analysis was assessed using univariate and multivariable analyses. By performing whole-genome sequencing of matched cfDNA and osteosarcoma tissue samples, we investigated the correlation between the size and mutation profiles of cfDNA and the mutation concordance between cfDNA and paired tissue tumors. RESULTS: The size of cfDNA fragments in patients with osteosarcoma was significantly shorter than in healthy donors, with the integrative analysis of size distribution and level of cfDNA achieving a high specificity and sensitivity of 100%. The short cfDNA fragment (150-bp cut-off) was an independent prognostic predictor in this osteosarcoma cohort [HR, 9.03; 95% confidence interval (CI), 1.13-72.20; P = 0.038]. Shortened cfDNA fragments were found to be a major source of mutations. Enrichment of cfDNA fragments with less than or equal to 150 bp by in silico size selection remarkedly improved the detection of copy-number variation signals up to 2.3-fold when compared with total cfDNA, with a higher concordance rate with matched osteosarcoma tissue. CONCLUSIONS: This finding demonstrated the potential of cfDNA size profiling in the stratification of poor prognostic patients with osteosarcoma. The short fragments of cfDNA are a promising source for boosting the detection of significant mutations in osteosarcoma. See related commentary by Weiser et al., p. 2017.

Impact of Sustained Synovitis on Knee Joint Structural Degeneration: 4-Year MRI Data from the Osteoarthritis Initiative.

BACKGROUND: Synovial inflammation is a risk factor for osteoarthritis (OA). But to date, there is limited information on how inflammation impacts progression of knee OA. PURPOSE: To investigate how sustained synovitis, assessed with semi-quantitative magnetic resonance imaging (MRI) scores, impacts progression of knee degenerative changes over 4 years. STUDY TYPE: Retrospective cohort study. SUBJECTS: In 249 participants (N = 132 women [53%]), from the Osteoarthritis Initiative (OAI) two definitions for synovitis were used resulting in two groups of participants with sustained synovitis at baseline, 2-year, and 4-year follow-up (N = 80 and N = 132), and two groups without synovitis at all three time points (N = 81 and N = 47). FIELD STRENGTH/SEQUENCE: 3 T intermediate-weighted (IW) turbo spin-echo (TSE) sequence and three-dimensional (3D) dual-echo steady-state (DESS) sequence. ASSESSMENT: Synovitis was scored semi-quantitatively using the Anterior Cruciate Ligament Osteoarthritis Score (ACLOAS), MRI Osteoarthritis Knee Score (MOAKS), and synovial proliferation score (SPS). Two MRI-based definitions of synovitis were used: (i) score ≥2 based on cumulative score of MOAKS and ACLOAS, and (ii) score ≥3 based on the cumulative score of ACLOAS, MOAKS, and SPS. Changes in structural abnormalities from baseline to year 4 measured using the whole-organ MRI score (WORMS) were defined as outcomes. STATISTICAL TESTS: Linear regression models were used to compare the differences in longitudinal changes in WORMS scores between participants with and without sustained synovitis for each definition of sustained synovitis. A P-value of <0.05 was considered statistically significant. RESULTS: Significantly higher rates of progression were found in participants with synovitis for patellar (Beta coeff. = 0.29) and medial tibial cartilage abnormalities (Beta coeff. = 0.29) for definition (i). For definition (ii), patellar (Beta coeff. = 0.36) and medial femoral cartilage (Beta coeff. = 0.30) abnormalities demonstrated significant differences. DATA CONCLUSION: Greater progression of structural degenerative disease was observed in individuals with sustained synovitis compared to those without sustained synovitis, suggesting that sustained synovitis is associated with progressive OA. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 2.

Diagnostic value of fluoroscopy-guided hip aspiration for periprosthetic joint infection.

PURPOSE: To assess the value of preoperative joint aspiration in detecting periprosthetic joint infection (PJI) in patients undergoing revision hip arthroplasty and to compare these with the clinical findings, serum markers, and intraoperative findings. MATERIALS AND METHODS: Fluoroscopically guided hip aspirations in patients with pain after hip arthroplasty were retrospectively reviewed from January 2014 to December 2018. All hips underwent subsequent revision hip arthroplasty. Antibiotics were discontinued at least 2 weeks before the aspiration. The 2018 Musculoskeletal Infection Society (MSIS) criteria served as a standard of reference for PJI. Clinical, serum, synovial, and intraoperative parameters were recorded in all patients. Correlations between all parameters with PJI diagnosis were analyzed using linear and logistic regression models with ROC analysis. RESULTS: In 202 hips that included 91 septic hips, hip aspiration (AUC = 0.78) and intraoperative (0.80) parameters performed better than serum-based tests (0.64) and clinical parameters (0.68) in detecting PJI. Using MSIS criteria as a standard of reference, hip aspiration had a sensitivity of 64.0% and an accuracy of 78.5% for cultures and a sensitivity of 74.2% and an accuracy of 82.1% for synovial polymorphonuclear neutrophils% (PMN%). Results substantially improved sensitivity after excluding patients that were treated with antibiotics, particularly culture results. CONCLUSIONS: Preoperative hip aspiration showed good diagnostic performance in diagnosing PJI compared with MSIS criteria as a standard of reference. But a negative result from aspirate could not rule out PJI. Based on our findings, hip aspiration is an essential test for treatment planning in patients with pain after hip arthroplasty.

Predicting outcomes in patients undergoing intra-articular corticosteroid hip injections.

OBJECTIVE: To investigate the associations between clinical, procedural, and radiographic factors and outcomes of steroid hip injections, including long-term and immediate pain reduction, time to arthroplasty, time to reinjection, and the total number of injections. MATERIALS AND METHODS: All intra-articular anesthetic and steroid injections of the hip under fluoroscopic guidance between January 2014 and March 2016 were retrospectively reviewed. Hip radiographs were scored using the Kellgren-Lawrence (KL) and Osteoarthritis Research Society International (OARSI) scores. Immediate pain relief and response were evaluated using a change in visual analog scale and OMERACT-OARSI criteria respectively. Long-term pain relief was evaluated at 2­7 months after injection by reviewing the medical records. Correlation between patient characteristics, procedural variations, and radiographic factors with injection outcomes was analyzed by using linear and logistic regression models. RESULTS: Of 361 injections, 79.8% showed an immediate pain response and 32.7% had subjective long-term pain relief (> 2 months). There was no significant correlation between immediate pain relief and response with long-term pain relief and other outcomes. Older age and higher KL score, OARSI-central joint space narrowing (JSN), and inferior acetabular osteophyte were correlated with long-term pain relief (p = 0.01­0.03). Higher KL and OARSI grades, particularly JSN, were significantly correlated with increased immediate pain relief and total number of injections but decreased time to arthroplasty. Baseline pain positively correlated with immediate pain response (p < 0.001). CONCLUSIONS: Older patients with higher grades of radiographic OA and high baseline pain were good candidates for steroid injections, particularly for those patients awaiting hip arthroplasty.

Obese and overweight individuals have greater knee synovial inflammation and associated structural and cartilage compositional degeneration: data from the osteoarthritis initiative.

OBJECTIVE: This work aims to study (i) the relationship between body mass index (BMI) and knee synovial inflammation using non-contrast-enhanced MRI and (ii) the association of synovial inflammation versus degenerative abnormalities and pain. MATERIALS AND METHODS: Subjects with risk for and mild to moderate radiographic osteoarthritis were selected from the Osteoarthritis Initiative. Subjects were grouped into three BMI categories with 87 subjects per group: normal weight (BMI, 20-24.9 kg/m2), overweight (BMI, 25-29.9 kg/m2), and obese (BMI, ≥ 30 kg/m2), frequency matched for age, sex, race, Kellgren-Lawrence grade, and history of knee surgery and injury. Semi-quantitative synovial inflammation imaging biomarkers were obtained including effusion-synovitis, size and intensity of infrapatellar fat pad signal abnormality, and synovial proliferation score. Cartilage composition was measured using T2 relaxation time and structural abnormalities using the whole-organ magnetic resonance imaging score (WORMS). The Western Ontario and McMasters (WOMAC) Osteoarthritis Index was used for pain assessment. Intra- and inter-reader reproducibility was assessed by kappa values. RESULTS: Overweight and obese groups had higher prevalence and severity of all synovial inflammatory markers (p ≤ 0.03). Positive associations were found between synovial inflammation imaging biomarkers and average T2 values, WORMS maximum scores and total WOMAC pain scores (p < 0.05). Intra- and inter-reader kappa values for imaging biomarkers were high (0.76-1.00 and 0.60-0.94, respectively). CONCLUSION: Being overweight or obese was significantly associated with a greater prevalence and severity of synovial inflammation imaging biomarkers. Substantial reproducibility and high correlation with knee structural, cartilage compositional degeneration, and WOMAC pain scores validate the synovial inflammation biomarkers used in this study.

Comparison of three-dimensional and two-dimensional computed tomographies in the classification of acetabular fractures.

PURPOSE: This study compared the accuracy and timeliness of two-dimensional computed tomography (2DCT) and three-dimensional computed tomography (3DCT) in the diagnosis of different types of acetabular fractures and by different groups of interpreters using the Letournel and Judet classification system. METHODS: Twenty-five fractures cases, five each of five common types of acetabular fractures, were selected. Nineteen interpreters with different levels of experience (ten graduate trainees and nine radiologists) individually classified the fractures using multiplanar 2D and standardized 3DCT images. The 3DCT image set was comprised of 39 images of rotational views of the entire pelvis and the disarticulated fracture hip. Consensus reading by three experts served as a reference standard. RESULTS: Classification accuracy was 66% using 2DCT, increasing to 73% (p = 0.041) when 3DCT was used. Improvement occurred in the interpretation of transverse and posterior wall-type fractures (p < 0.01 and p = 0.015, respectively), but not in T-type, transverse with posterior wall, or both-column fractures. The improvement was noted only in the graduate trainee group (p = 0.016) but not the radiologist group (p = 0.619). Inter-observer reliability in the graduate trainee group improved from poor to moderate with 3DCT, but remained at a moderate level in both 2DCT and 3DCT in the radiologist group. The overall average interpretation time per case with correct diagnosis was 60 s for 2DCT but only 32 s for 3DCT. CONCLUSIONS: Standardized 3DCT provides greater reliability and faster diagnosis of acetabular fractures and helps improve the accuracy in transverse- and posterior wall-type fractures. In addition, it helps improve the accuracy of less experienced interpreters.

Efficacy of three-dimensional cinematic rendering computed tomography images in visualizing features related to age estimation in pelvic bones.

Morphological changes on the surface of the pelvic bone can be used to estimate the age at death of a person. These features can be visualized using three dimensional computed tomography (3D CT) images. A newly introduced 3D CT technique, cinematic volume rendering, improves visualization of the surface of bones by integrating the effect of light on the images. The aim of this study is to evaluate the efficacy of this 3D CT technique in visualizing features related to age estimation in pelvic bones. Dry pelvic bones of 35 subjects were scanned and then 3D reconstruction of the images was performed using the cinematic rendering technique. The 3D CT images of the pubic symphyses and the auricular surfaces were interpreted by two radiologists and a forensic osteologist using age estimation features derived from the Suchey-Brooks and the Buckberry-Chamberlain methods The interpretation of the dry pelvic bones was done by an expert anatomist and used as a gold standard. The percentages of correct interpretations and level of agreement in grading using 3D CT and using dry bones were high for features in the pubic symphyses including surface patterns (100%, k=1), presence of lower extremities (100%, k=1), and patterns of pubic rims (91.4%, range 87.5-100%, k=0.88). In the auricular surface of the ilium, all specimens with an apical activity were correctly interpreted (100%, k=1), but detection was moderate to poor for transverse organization (71.4%, k=0.43), macroporosity (70%, k=0.38.), and microporosity (52.9%, k=0.25). Cinematic volume rendering has a high level of efficacy in identifying age-related features on pubic symphyses, but it inadequately displays features on the auricular surface.

Value of ultrasonography in the diagnosis of gout in patients presenting with acute arthritis.

OBJECTIVE: To evaluate the value of ultrasonographic features of crystal deposition for diagnosing gout in patients presenting with acute arthritis. MATERIALS AND METHODS: Ultrasound scanning of the most inflamed joint was performed on 89 consecutively enrolled patients with acute arthritis. Two radiologists independently reviewed the ultrasound images, and a consensus was achieved with a third radiologist when the interpretations of four key ultrasound features of gout differed. Arthrocentesis and crystal analysis using compensated polarized light microscopy of aspirates are considered the gold standards for gout diagnosis. RESULTS: Fifty-three (60%) patients had gout, whereas the remaining 36 (40%) had non-gout arthritis. The mean serum uric acid level was 7.1 mg/dl in patients with gout and 4.7 mg/dl in patients with non-gout arthritis. Three US features differed significantly (p < 0.001) between patients with gout and non-gout arthritis: the double contour sign (42 vs. 8%, respectively), intra-articular aggregates (58 vs. 8%), and tophi (40 vs. 0%). No statistically significant differences in detecting intra-tendinous aggregates (32 vs. 17%, p = 0.14) were observed. The sensitivity and specificity of the double contour sign were 42 and 92%, respectively; those of the intra-articular aggregates were 58 and 92%; and those of tophi were 40 and 100%. The positive predictive values for these three features ranged from 88 to 100%, whereas the negative predictive values ranged from 52 to 60%. CONCLUSIONS: When the prevalence is high, these three ultrasound features may be a useful adjunct in the diagnosis of acute gout, particularly when specialized microscopic techniques are not available.

Acute bone infarction: a rare complication in thalassemia.

Acute bone infarction is a well-described complication in sickle cell hemoglobinopathy but it is rarely reported in patients with thalassemia. This report describes an 18-year-old man with homozygous ß-thalassemia presenting with a fever and severe acute bilateral ankle pain. The acute onset of severe pain and fever were clinical mimics of infectious arthritis and osteomyelitis. Magnetic resonance imaging revealed acute bone infarction in the meta-diaphysis of bilateral tibias presenting as central unenhanced devitalized bone with T1-high signal intensity fluid in the subperiosteum and soft tissue. Characteristic imaging features are discussed, emphasizing the benefit of fat suppression pre-and post-intravenous gadolinium T1-weighted images. The etiologies of bone infarction in thalassemia are reviewed.