The lumbar artery perforator flap: clinical review and guidance on image reporting.

The lumbar artery perforator (LAP) flap is a relatively new procedure that can be utilized to manage lumbosacral defects in addition to reconstructing distal body parts as well, such as breast reconstruction. This fasciocutaneous flap is designed based on the LAPs small arteries that emerge from the lumbar arteries then move superficially piercing overlying tissues to perforate the lumbar fascia and supply the skin and subcutaneous tissue; However, anatomical and clinical studies regarding the LAP flap and its perforators are sparse in the literature, and the results are even contradicting. This article will discuss the LAP flap, the anatomy of its perforators, and the clinical aspects about its usage. In addition, we explore its preoperative imaging evaluation, and deliver a guide on image reporting and radiological data that will benefit the surgeon most during the procedure.

Assessing vascular effects of adding bevacizumab to neoadjuvant chemotherapy in osteosarcoma using DCE-MRI.

BACKGROUND: The purpose of this study was to assess the impact of bevacizumab alone and in combination with cytotoxic therapy on tumour vasculature in osteosarcoma (OS) using DCE-MRI. METHODS: Six DCE-MRI and three (18)F-FDG PET examinations were scheduled in 42 subjects with newly diagnosed OS to monitor the response to antiangiogenic therapy alone and in combination with cytotoxic therapy before definitive surgery (week 10). Serial DCE-MRI parameters (K(trans), v(p), and v(e)) were examined for correlation with FDG-PET (SUV(max)) and association with drug exposure, and evaluated with clinical outcome. RESULTS: K(trans) (P=0.041) and v(p) (P=0.001) significantly dropped from baseline at 24 h after the first dose of bevacizumab alone, but returned to baseline by 72 h. Greater exposure to bevacizumab was correlated with larger decreases in v(p) at day 5 (P=0.04) and week 10 (P=0.02). A lower K(trans) at week 10 was associated with greater percent necrosis (P=0.024) and longer event-free survival (P=0.034). CONCLUSIONS: This is the first study to demonstrate significant changes of the plasma volume fraction and vascular leakage in OS with bevacizumab alone. The combination of demonstrated associations between drug exposure and imaging metrics, and imaging metrics and patient survival during neoadjuvant therapy, provides a compelling rationale for larger studies using DCE-MRI to assess vascular effects of therapy in OS.

Tumour response interpretation with new tumour response criteria vs the World Health Organisation criteria in patients with bone-only metastatic breast cancer.

BACKGROUND: We compared the utility of a new response classification (MDA; based on computed tomography (CT), magnetic resonance imaging (MRI), plain radiography (XR), and skeletal scintigraphy (SS)) and the World Health Organisation response classification (WHO; based on XR and SS) in stratifying breast cancer patients with bone-only metastases with respect to progression-free survival (PFS), overall survival (OS), and clinical response. METHODS: We retrospectively reviewed 41 patients with bone-only metastatic breast cancer and assigned responses according to the MDA and WHO criteria. We analysed whether the MDA or WHO response classifications correlated with PFS and OS. RESULTS: With the MDA criteria, there were significant differences in PFS between patients classified as responders and those classified as nonresponders (P=0.025), but with the WHO criteria, there were not. Neither criteria distinguished responders from nonresponders in terms of OS. MDA response criteria correlated better than WHO response criteria with clinical response assessment. CONCLUSIONS: The MDA classification is superior to the WHO classification in differentiating between responders and nonresponders among breast cancer patients with bone-only metastases. Application of the MDA classification may allow bone lesions to be considered measurable disease. Prospective study is needed to test the MDA classification among patients with bone metastasis.

Role of chemotherapy in dedifferentiated liposarcoma of the retroperitoneum: defining the benefit and challenges of the standard.

Benefit from chemotherapy for well-differentiated/de-differentiated (WD/DD) liposarcomas has been reported to be minimal, however traditional response criteria may not adequately capture positive treatment effect. In this study, we evaluate benefit from first-line chemotherapy and characterize imaging response characteristics in patients with retroperitoneal (RP) WD/DD liposarcoma treated at The University of Texas MD Anderson Cancer Center. Response was assessed using RECIST (Response Evaluation Criteria in Solid Tumors) and an exploratory analysis of vascular response was characterized. Among 82 patients evaluable for response to first-line therapy, 31 patients received neoadjuvant chemotherapy for localized/locally advanced disease; 51 received chemotherapy for unresectable recurrent/metastatic disease. Median overall survival from the start of chemotherapy was 29 months (95% CI 24-40 months). Response rates by RECIST: partial response (PR) 21% (17/82), stable disease (SD) 40%, and progression (PD) 39%. All RECIST responses were in patients receiving combination chemotherapy. A qualitative vascular response was seen in 24 patients (31%). Combination chemotherapy yields a response rate of 24% and a clinical benefit rate (CR/PR/SD > 6 months) of 44%, higher than previously reported in DD liposarcoma. A higher percentage of patients experience a vascular response with chemotherapy that is not adequately captured by RECIST in these large heterogeneous tumors.

Osseous Pseudoprogression in Vertebral Bodies Treated with Stereotactic Radiosurgery: A Secondary Analysis of Prospective Phase I/II Clinical Trials.

BACKGROUND AND PURPOSE: Osseous pseudoprogression on MR imaging can mimic true progression in lesions treated with spine stereotactic radiosurgery. Our aim was to describe the prevalence and time course of osseous pseudoprogression to assist radiologists in the assessment of patients after spine stereotactic radiosurgery. MATERIALS AND METHODS: A secondary analysis of 2 prospective trials was performed. MRIs before and after spine stereotactic radiosurgery were assessed for response. "Osseous pseudoprogression" was defined as transient growth in signal abnormality centered at the lesion with a sustained decline on follow-up MR imaging that was not attributable to chemotherapy. RESULTS: From the initial set of 223 patients, 37 lesions in 36 patients met the inclusion criteria and were selected for secondary analysis. Five of the 37 lesions (14%) demonstrated osseous pseudoprogression, and 9 demonstrated progressive disease. There was a significant association between single-fraction therapy and the development of osseous pseudoprogression (P = .01), and there was a significant difference in osseous pseudoprogression-free survival between single- and multifraction regimens (P = .005). In lesions demonstrating osseous pseudoprogression, time-to-peak size occurred between 9.7 and 24.4 weeks after spine stereotactic radiosurgery (mean, 13.9 weeks; 95% CI, 8.6-19.1 weeks). The peak lesion size was between 4 and 10 mm larger than baseline. Most lesions returned to baseline size between 23 and 52.4 weeks following spine stereotactic radiosurgery. CONCLUSIONS: Progression on MR imaging performed between 3 and 6 months following spine stereotactic radiosurgery should be treated with caution because osseous pseudoprogression may be seen in more than one-third of these lesions. Single-fraction spine stereotactic radiosurgery may be associated with osseous pseudoprogression. The possibility of osseous pseudoprogression should be incorporated into the prospective criteria for assessment of local control following spine stereotactic radiosurgery.

Persistent interstitial pulmonary emphysema: another complication of the respiratory distress syndrome.

Persistent interstitial pulmonary emphysema (PIPE) was observed in 22 infants during the neonatal period. All of the infants experienced respiratory distress during the first few days of life, and 21 of them were treated for the respiratory distress syndrome with artificial ventilation or oxygen or both. Ten infants developed a localized form of PIPE, with air-filled interstitial cysts measuring up to 3.0 cm in diameter confined to one or more lobes of lung. The involved segment of lung was resected in seven of these infants, all of whom survived. The remaining three died and autopsies were performed. A diffuse form of PIPE was observed in the other 12 infants. Numerous cysts that were predominantly small (less than 0.3 cm) were seen in all lobes of both lungs. These infants received high concentrations of oxygen for prolonged periods, resulting in bronchopulmonary dysplasia in 11 of the infants. All 12 infants died. PIPE is characterized histologically by air-filled interstitial cysts partially lined by multi-nucleated giant cells.

Radionuclide bone scanning in giant cell tumor.

Radionuclide bone scan findings are described and correlated with pathology in 23 patients with giant cell tumor (GCT) of the bone. The degree of radionuclide activity was markedly increased in 20 (87%), minimally increased in three (13%), and decreased in none of the patients. Of the 23 patients with increased radioactivity, the pattern was diffuse in 11 (48%) and doughnut in 12 (52%). Extended patterns of radioactivity were present in 19 of 22 patients; however, none were associated with true tumor extension. Bone scanning did not aid in the detection of GCT, was nonspecific, and did not differentiate benign from malignant GCT. Although radioactivity extended beyond the radiographic abnormality in the majority of patients, this was most likely secondary to other bony abnormalities or local and/or regional hyperemia, and caution should be taken in ascribing this extension to either tumor or metastasis.

Congenital cystic adenomatoid malformation of the lung. Classification and morphologic spectrum.

Thirty-eight cases of congenital cystic adenomatoid malformation of the lung are described, and a classification based on clinical, gross, and microscopic criteria is proposed. The type I lesion is composed of single or multiple large cysts (more than 2 cm. in diameter), frequently producing mediastinal herniation. The cysts are lined by ciliated psuedostratified columnar epithelium. The walls of the cysts contain prominent smooth muscle and elastic tissue. Mucus producing cells are present in approximatley one-third of the cases, and cartilage in the wall is rarely seen. Relatively normal alveoli may be seen between the cysts. The prognosis is good. Radiographic analysis of the type I lesion can preoperatively suggest the diagnosis, especially with the typical multicystic pattern. The gross appearance of the lesion corresponds closely to the radiographic image and adds another dimension to the pathologist's evaluation of the disease. The type II lesion is composed of multiple small cysts (less than 1 cm. in diameter) lined by ciliated cuboidal to columnar epithelium. Structures resembling respiratory bronchioles and distended alveoli are present between the epithelium lined cysts. Mucous cells and cartilage are not present. Striated muscle fibers may be seen rarely. The type II lesion is associated with a high frequency of other congenital anomalies, and the prognosis is poor. The type III lesion is a large, bulky noncystic lesion producing mediastinal shift. Bronchiole-like structures are lined by ciliated cuboidal epithelium and separated by masses of alveolus-sized structures lined by nonciliated cuboidal epithelium. The prognosis is poor.

An approach to primary bone tumors.

This article is designed to provide the busy, practicing physician with the essential information needed to approach the patient with a primary bone tumor. An algorithm provides a suitable method of assessing most patients with bone tumors, recognizing slight modification is necessary in each case. Following this approach should allow successful accomplishment of the therapeutic triad: (1) do not "over-treat" a benign bone tumor, (2) do not "under-treat" a malignant bone tumor, and (3) do not misdirect the biopsy approach to the lesion so as to convert a more conservative operation into a more radical operation.

Rheumatoid and seronegative arthropathies of the foot.

The foot is often involved in rheumatoid arthritis and its seronegative variants. This article presents an overview of the subject and highlights the various distinguishing features of these arthritic disorders in the foot.

The normal and abnormal growth plate.

Skeletal growth is a dynamic process. A knowledge of the structure and function of the normal growth plate is essential in order to understand the pathophysiology of abnormal skeletal growth in various diseases. In this well-illustrated article, the authors provide a radiographic classification of abnormal growth plates and discuss mechanisms that lead to growth plate abnormalities.

Osteomyelitis, acute and chronic.

In certain patient populations, osteomyelitis is a significant clinical problem. The judicious use of plain film radiographs and radionuclide bone imaging by the imaging consultant has a critical role in the early detection and diagnosis of osteomyelitis. This complementary imaging approach produces the highest and greatest accuracy in the documentation of skeletal infections. Inadvertent delay in the initiation of appropriate therapy can be obviated utilizing these imaging techniques and undue morbidity averted.

Radiologic and pathologic analysis of solitary bone lesions. Part I: internal margins.

The interface between tumor and bone that is displayed radiographically is a zone of cellular activity. Its radiographic appearance represents the summation of bone lysis and production. This activity and the radiographic details of the resultant margin are an index of the biologic activity of a lesion. The anatomic site and extent of the lesion can be assessed by radiographs and special imaging techniques. Careful analysis of these patterns, when integrated with clinical data, enhances diagnosis, patient management, and therapy.

Radiologic and pathologic analysis of solitary bone lesions. Part II: periosteal reactions.

The activated periosteum has a deceptive anatomic constancy amidst change. The change involves the production of matrix and, in the process, proliferation and expenditure of cells. When the demand for a reaction is excessive, nearby extraperiosteal soft tissue serves as a ready source for additional modulating cells, just as it does for fracture callus. The configuration of a periosteal reaction is an index of the nature and intensity of the inciting process.

Radiologic and pathologic analysis of solitary bone lesions. Part III: matrix patterns.

The mineralized matrix patterns demonstrated in clinical radiographs of primary bone neoplasms and related disorders help to predict matrices, and have diagnostic significance. These radiographic patterns may yield important clues as to the true nature of a lesion, especially when only limited biopsy material is available from extraosseous or nonrepresentative areas. Therefore, in the evaluation of bone tumors and tumor-like conditions, it is of extreme importance to correlate the histologic findings with the radiographic examination and to know precisely the location at which the biopsy material was obtained. Patterns of mineralization may be the only remnants of a pre-existing lesion that has undergone sarcomatous transformation, such as in bone infarcts, enchondromas, or osteochondromas. The pre-eminent item of importance for patient care is the diagnosis of a malignant process. However, failure to appreciate antecedent benign conditions will not contribute toward a better understanding of tumor biology or a determination of those benign lesions that warrant removal or close clinical follow-up. Integration of matrix data with knowledge of the anatomic location of a lesion, the character of its margins, and the periosteal reaction patterns it produces permits prognostication and often, specific diagnosis.

MR imaging of periarticular soft-tissue lesions.

The exquisite soft-tissue contrast and multi-planar imaging capabilities of MR imaging uniquely qualify this modality for the evaluation of periarticular pathology. MR evaluation can be diagnostic by signal characterization, as in a lipoma, or by anatomic location, as seen in meniscal and synovial cysts. In other less diagnostic pathology, MR imaging can focus a differential diagnosis, guide percutaneous or surgical biopsy, provide local staging, and serve as a surgical map.

Benign fibrous histiocytoma: a rare endobronchial neoplasm.

Fibrous histiocytomas are rarely found within the lung and have presented as a mass within a major airway only twice previously. This is the third reported case of such a tumor visualized roentgenographically in an airway on the frontal chest film of a patient presenting with recurrent pneumonia.

Role of radiology in aviation accident investigation.

Radiographic screening of fatality victims for skeletal detail, dental and surgical artifacts, personal effects, and foreign bodies is of established value. Radiography as the primary means of positive victim identification, through comparison with antemortem films and records, is an important new role. Data on sources of injury and relationships between victims and the crash environment may be derived from radiographic injury patterns and may be correlated with mechanisms of injury production. The result of such analysis is improved safety design. Such radiography poses unique technical and logistical problems, often involving temporary or remote facilities, which must be solved with consideration for privacy and safety. Advance planning is essential for maximum benefit from radiographic investigation.