Soft tissue tumor imaging in adults: whole-body staging in sarcoma, non-malignant entities requiring special algorithms, pitfalls and special imaging aspects. Guidelines 2024 from the European Society of Musculoskeletal Radiology (ESSR).

OBJECTIVES: The revised European Society of Musculoskeletal Radiology (ESSR) consensus guidelines on soft tissue tumor imaging represent an update of 2015 after technical advancements, further insights into specific entities, and revised World Health Organization (2020) and AJCC (2017) classifications. This second of three papers covers algorithms once histology is confirmed: (1) standardized whole-body staging, (2) special algorithms for non-malignant entities, and (3) multiplicity, genetic tumor syndromes, and pitfalls. MATERIALS AND METHODS: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements that had undergone interdisciplinary revision were scored online by the level of agreement (0 to 10) during two iterative rounds, that could result in 'group consensus', 'group agreement', or 'lack of agreement'. RESULTS: The three sections contain 24 statements with comments. Group consensus was reached in 95.8% and group agreement in 4.2%. For whole-body staging, pulmonary MDCT should be performed in all high-grade sarcomas. Whole-body MRI is preferred for staging bone metastasis, with [18F]FDG-PET/CT as an alternative modality in PET-avid tumors. Patients with alveolar soft part sarcoma, clear cell sarcoma, and angiosarcoma should be screened for brain metastases. Special algorithms are recommended for entities such as rhabdomyosarcoma, extraskeletal Ewing sarcoma, myxoid liposarcoma, and neurofibromatosis type 1 associated malignant peripheral nerve sheath tumors. Satisfaction of search should be avoided in potential multiplicity. CONCLUSION: Standardized whole-body staging includes pulmonary MDCT in all high-grade sarcomas; entity-dependent modifications and specific algorithms are recommended for sarcomas and non-malignant soft tissue tumors. CLINICAL RELEVANCE STATEMENT: These updated ESSR soft tissue tumor imaging guidelines aim to provide support in decision-making, helping to avoid common pitfalls, by providing general and entity-specific algorithms, techniques, and reporting recommendations for whole-body staging in sarcoma and non-malignant soft tissue tumors. KEY POINTS: An early, accurate, diagnosis is crucial for the prognosis of patients with soft tissue tumors. These updated guidelines provide best practice expert consensus for standardized imaging algorithms, techniques, and reporting. Standardization can improve the comparability examinations and provide databases for large data analysis.

Temporal and masseter muscle evaluation by MRI provides information on muscle mass and quality in acromegaly patients.

PURPOSE: The impact of GH/IGF-1 levels on skeletal muscle in acromegaly is still controversial. Temporal (TMT) and masseter muscle (MMT) thickness has been recently demonstrated as a reliable measure of muscle mass. We aimed to investigate the relationship between TMT, MMT and clinical/biochemical characteristics in patients with acromegaly. METHODS: Single center retrospective longitudinal study including 69 patients with at least one available brain/sella turcica MRI and matched clinical data. TMT, MMT, and muscle fatty infiltration (modified Goutallier score) were evaluated in all patients at baseline (first available MRI) and over time (182 MRIs analyzed). RESULTS: At baseline, both TMT and MMT were higher in males than females (p = 0.001 and p = 0.016, respectively). TMT and MMT were positively associated (ß 0.508, p < 0.001), and they were positively correlated with IGF-1 xULN (TMT, p = 0.047; MMT, p = 0.001). MMT had a positive correlation with patients' weight (p = 0.015) and height (p = 0.006). No correlation was found between TMT, MMT and the presence of hypogonadism. Considering all available MRIs, sex and IGF-1 xULN were significant determinants of TMT and MMT at multivariable analysis (female sex: ß -0.345/-0.426, p < 0.001; IGF-1 xULN: ß 0.257/0.328, p < 0.001). At longitudinal evaluation, uncontrolled patients at baseline showed a significant reduction of MMT over time (p = 0.044). Remarkable fatty infiltration was observed in 34-37% of MRIs; age was the main determinant (temporal muscle: OR 1.665; p = 0.013; masseter muscle: OR 1.793; p = 0.009). CONCLUSION: Male patients with higher IGF-1 values have thicker temporal and masseter muscles, suggesting that sex and IGF-1 have a significant impact on muscle mass in acromegaly.

Circulating Osteopontin Predicts Clinical and Radiological Response in First-Line Treatment of Advanced Non-Small Cell Lung Cancer.

PURPOSE: Pembrolizumab-based regimens are conditioned by the expression of PD-L1, but durable response rate is limited by innate and acquired resistance mechanisms. Here, we focus on osteopontin (OPN), an upfront biomarker of senescence, which closely associated with natural history of non-small cell lung cancer (NSCLC). METHODS: Seventy-nine patients eligible to pembrolizumab regimens-alone or in combination with chemotherapy-as first-line treatment of advanced NSCLC were enrolled. Predictive value of OPN toward iRECIST progression disease (PD) was set as first outcome. Secondary ones included performance status (ECOG) at baseline, early (first and best) responses, and overall survival (OS). RESULTS: High Serum OPN characterized patients with worse ECOG-PS (p = 0.015) at baseline and subjects experienced PD/death at first (OR 1.17 [1.02 to 1.35]; p = 0.030) and best responses (0.04 [0.00 to 0.81]; p = 0.035). OPN was associated with time-to-progression (B -2.74 [-4.46 to -1.01]) and time-to death (-0.13 [-0.20 to -0.05]). Cox regression models unveil a predictive value for iRECIST-PD (HR 1.01 [1.00 to 1.02]; p = -0.005), RECIST-PD (HR 1.01 [1.00 to 1.02]; p = 0.017), and OS (HR 1.02 [1.01 to 1.03]; p = 0.001). These models were internally validated through bootstrap resampling and characterized by relevant discrimination ability at ROC curve analyses. CONCLUSION: Baseline levels of serum OPN is closely associated with performance status and short/long term outcomes in patients with advanced NSCLC, which are candidate to pembrolizumab-based regimens. As upfront biomarker of senescence, OPN may pave the way for future studies focusing on senescence patterns in NSCLC.

Radiological diagnosis of prevalent osteoporotic vertebral fracture on radiographs: an interim consensus from a group of experts of the ESSR osteoporosis and metabolism subcommittee.

When a low-energy trauma induces an acute vertebral fracture (VF) with clinical symptoms, a definitive diagnosis of osteoporotic vertebral fracture (OVF) can be made. Beyond that, a "gold" radiographic standard to distinguish osteoporotic from non-osteoporotic VFs does not exist. Fracture-shaped vertebral deformity (FSVD) is defined as a deformity radiographically indistinguishable from vertebral fracture according to the best of the reading radiologist's knowledge. FSVD is not uncommon among young populations with normal bone strength. FSVD among an older population is called osteoporotic-like vertebral fracture (OLVF) when the FSVD is likely to be associated with compromised bone strength. In more severe grade deformities or when a vertebra is collapsed, OVF diagnosis can be made with a relatively high degree of certainty by experienced readers. In "milder" cases, OVF is often diagnosed based on a high probability rather than an absolute diagnosis. After excluding known mimickers, singular vertebral wedging in older women is statistically most likely an OLVF. For older women, three non-adjacent minimal grade OLVF (< 20% height loss), one minimal grade OLVF and one mild OLVF (20-25% height loss), or one OLVF with ≥ 25% height loss, meet the diagnosis of osteoporosis. For older men, a single OLVF with < 40% height loss may be insufficient to suggest the subject is osteoporotic. Common OLVF differential diagnoses include X-ray projection artifacts and scoliosis, acquired and developmental short vertebrae, osteoarthritic wedging, oncological deformities, deformity due to high-energy trauma VF, lateral hyperosteogeny of a vertebral body, Cupid's bow, and expansive endplate, among others.

High incidence of RAMP lesions and a nonnegligible incidence of anterolateral ligament and posterior oblique ligament rupture in acute ACL injury.

PURPOSE: The purpose of this study was to assess the frequency of medial collateral ligament (MCL), posterior oblique ligament (POL) and anterolateral ligament (ALL) tears and different types of RAMP lesions of patients with verified acute anterior cruciate ligament (ACL) tears by magnetic resonance imaging (MRI). METHODS: MRI was performed on patients with a clinical diagnosis of acute ACL injury. Patients were eligible for inclusion if they had an initially clinically noted ACL tear confirmed on MRI within 30 days of trauma. RESULTS: A total of 146 patients were included in the study, 42 (28.8%) females and 104 (71.2%) males. The mean age at MRI was 27.2 ± 9.4 years, and the mean time from injury to MRI was 15.7 ± 7.8 days. Thirty-four (23.3%) patients had a complete MCL lesion, 32 (21.9%) had a complete POL lesion and 28 (19.2%) had a complete ALL lesion. One hundred and fourteen patients (78.1%) presented with RAMP lesions, while 20 (13.7%) patients reported other meniscal lesions. The mean medial and lateral tibial slopes were 4.0° ± 2.7° and 4.0° ± 3.1°, respectively. Only 10 (6.8%) patients reported no lesions associated with ACL rupture. The most common injuries were isolated RAMP type 3 (18-12.3%) and isolated RAMP type 1 (17-11.6%). Thirteen (8.9%) patients had a combination of MCL, POL and ALL rupture. CONCLUSIONS: Isolated lesions of the ACL are extremely rare. In most cases, a single RAMP lesion should be investigated. In the presence of MCL injury, POL injury should always be suspected as well, while nearly 20% of patients present a rupture of the ALL. About one in 10 patients had three lesions (MCL, ALL and POL), and most of them had a combined RAMP lesion. LEVEL OF EVIDENCE: Level IV.

Long-term outcome of 9G MRI-guided vacuum-assisted breast biopsy: results of 293 single-center procedures and underestimation rate of high-risk lesions over 12 years.

PURPOSE: Breast magnetic resonance imaging (MRI) can detect some malignant lesions that are not visible on mammography (MX) or ultrasound (US). If a targeted, second-look fails, MRI-guided breast biopsy is the only available tool to obtain a tissue sample and pathological proof of these "MRI-only lesions". The aim of this study is to report the performance and underestimation rate of 9G MRI-guided vacuum-assisted breast biopsy (VABB) over 12 years at a single center. MATERIAL AND METHODS: All 9G MRI-VABB procedures performed from January 2010 to December 2021 were retrospectively reviewed. Two MRI scanners (1.5 T and 3 T) were used with the same image resolution and contrast media. All suspicious lesions detected only by breast MRI underwent biopsy. Reference standard was histological diagnosis or at least 1-year negative follow-up. All malignant and atypical lesions underwent surgery, which was used as the reference standard. RESULTS: A total of 293 biopsies were retrospectively reviewed. Histopathological VABB results revealed 142/293 (48.4%) benign lesions, 77/293 (26.2%) high-risk lesions, and 74/293 (25.2%) malignant lesions. No significant complications were observed. Surgical pathology results allowed for the reclassification of n = 7/48 B3b lesions: n = 4 were ductal carcinoma in situ, while n = 3 presented invasive features at surgical histology (2 IDC; 1 ILC). B3b underestimation occurred overall in 14.6% of B3 cases. Breast follow-up was achieved for all benign VABB results, and only one false-negative case was observed. CONCLUSION: Our results confirm that 1.5 T and 3 T MRI-guided VABB is an accurate and safe procedure for histopathologic final diagnosis of MRI-only lesions. Critical issues remain the potential high-risk underestimation rate of B3b VABB results and management of follow-up of benign lesions.

Skeletal Muscle Evaluation in Patients With Acromegaly.

Context: Patients with acromegaly are characterized by chronic exposure to high growth hormone (GH) and insulin-like growth factor-1 levels, known for their anabolic effect on skeletal muscle. Therefore, an increased skeletal muscle mass could be hypothesized in these individuals. Herein, we have performed a systematic revision of published evidence regarding skeletal muscle mass, quality, and performance in patients with acromegaly. Evidence Acquisition: A systematic review of the literature in the PubMed database up to September 1, 2023, was conducted with the following query: acromegaly AND ("muscle mass" OR "skeletal muscle"). We excluded studies that did not compare different disease states or used nonradiological methods for the skeletal muscle analyses, except for bioelectrical impedance analysis. Evidence Synthesis: Fifteen studies met the inclusion criteria. A total of 360 patients were evaluated for skeletal muscle mass, 122 for muscle fatty atrophy, and 192 for muscle performance. No clear evidence of increased skeletal muscle mass in patients with active disease compared to control or healthy individuals emerged. As for skeletal muscle quality, we observed a trend toward higher fatty infiltration among patients with acromegaly compared to healthy participants. Likewise, patients with active disease showed consistently worse physical performance compared to control or healthy individuals. Conclusion: Skeletal muscle in acromegaly has lower quality and performance compared to that of healthy individuals. The small number of published studies and multiple confounding factors (eg, use of different radiological techniques) contributed to mixed results, especially regarding skeletal muscle mass. Well-designed prospective studies are needed to investigate skeletal muscle mass in patients with acromegaly.