Image-guided core needle biopsy for Ewing sarcoma of bone: a 10-year single-institution review.

OBJECTIVE: To evaluate the performance of image-guided core needle biopsy (IGCNB) for the diagnosis of Ewing sarcoma of bone. METHODS: All patients with a confirmed diagnosis of Ewing sarcoma who underwent IGCNB between January 2007 and December 2016 were included in this retrospective study. Analysis included mean age, skeletal distribution, imaging modality used for biopsy guidance, type of anaesthesia, needle type, number of passes, type of tissue sampled, and complications. RESULTS: The study included 139 patients (94 males and 45 females; mean age 18.7 years) who underwent 141 image-guided core needle biopsies as the primary diagnostic test. Of these, 101 were CT-guided, 38 ultrasound-guided, and 2 utilised both CT and ultrasound guidance. A total of 97.9% were diagnostic at first procedure. Of the 3 non-diagnostic cases, 2 underwent a further IGCNB and were positive, while 1 patient required an open surgical procedure. Only 1 patient (0.7%) suffered an immediate complication, and there were no recorded delayed complications. CONCLUSION: IGCNB is a safe procedure providing a positive diagnosis of Ewing sarcoma of bone in a very high percentage of cases. It should be the first-line method for establishing a diagnosis in suspected Ewing sarcoma of bone. KEY POINTS: • Image-guided core needle biopsy is a safe procedure providing a positive diagnosis of Ewing sarcoma of bone in a very high percentage of cases. • Image-guided core needle biopsy should be the first-line method for establishing a definitive diagnosis in Ewing sarcoma and should be performed at a specialist sarcoma referral centre. • When technically feasible, extra-osseous soft tissue alone can be sampled with confidence as there is no difference in diagnostic performance whether bone or an extra-osseous soft tissue component of the tumour is sampled.

Ganglion cyst arising from the transverse acetabular ligament (TAL): a rare cause of entrapment of the anterior branch of the obturator nerve. Case report and review of the literature.

The transverse acetabular ligament is an unusual location for ganglion cysts. Only a few cases have been reported in the literature. They can be asymptomatic and represent an incidental finding or can cause an atypical pattern of hip joint/groin pain. We report a case of ganglion cyst arising from the TAL causing entrapment of the anterior branch of the obturator nerve with associated acute denervation of the abductor longus (AL), adductor brevis (AB), and gracilis muscles.

Magnetic Resonance Imaging Features of Cervical Spine Intraspinal Extradural Synovial Cysts.

Spinal synovial cysts are relatively uncommon and are most frequently found in the lumbar spine and rarely in the cervical spine. Intraspinal extradural cervical synovial cysts can occur and potentially cause cord/nerve root compression with symptoms of myelopathy/radiculopathy; however, most are asymptomatic and incidental findings. We conducted a literature review and present, to our knowledge, the largest imaging case series and describe the magnetic resonance imaging features of cervical synovial cysts.

Experience of neuroprotective air injection during radiofrequency ablation (RFA) of spinal osteoid osteoma.

PURPOSE: To assess the usefulness of epidural air injection during the RFA treatment of spinal osteoid osteoma. METHODS: A retrospective review of 17 patients who underwent RFA for spinal osteoid osteoma between September 2006 and May 2017 was performed. All the procedures were performed by a single radiologist. We reviewed the perioperative CT studies to assess the distribution of air relative to the osteoid osteoma. The clinical outcome of each patient group was evaluated during routine follow-up. RESULTS: Seventeen patients were treated for spinal OO (male:female 13:4; mean age was 16, ranging from 4 to 42). The nidus size ranged from 5.8 to 17.2 mm (mean 11.2). In nine cases epidural air injection was performed. In three cases the neuroprotective air was deemed satisfactory with a clear layer of air between the osteoid osteoma and the dural sac being visualised. In six patients adherence between the cortical bone immediately adjacent to the osteoid osteoma and the dural sac in contact was observed. In 15 patients the procedure was successful in terms of pain relief. No neural damage or other complication was reported in either group. CONCLUSION: RFA is a safe treatment for spinal osteoid osteoma. Neuroprotective air injection does not appear to be necessary when performing the treatment in the spine. KEY POINTS: • Seventeen patients with spinal OO were treated with RFA, nine with air injection and eight without. Clinically successful treatment was achieved in 15 patients, with 2 subsequently undergoing surgery • In 6/9 cases the injected air failed to achieve separation between the osteoid osteoma and the thecal sac because of inflammatory adhesion • No complications were observed, regardless of whether neuroprotective air was instilled. Neuroprotective air injection appears unnecessary when treating spinal OO.

Ethyl chloride spray for musculoskeletal ultrasound-guided injections: An alternative to subcutaneous injection of local anesthetic solution.

Ultrasound-guided injections such as steroid injections are common procedures involving the musculoskeletal system. They are usually performed after a subcutaneous injection of local anesthetic (LA), which can be painful. In 126 consecutive patients, local anesthesia was performed using ethyl chloride spray prior to a therapeutic ultrasound-guided injection in joints, tendons, or bursae. Ninety-nine (78.5%) patients found the use of ethyl chloride spray helpful. The use of ethyl chloride spray is an effective, patient-friendly alternative to the standard injection of local aesthetic for ultrasound-guided therapeutic musculoskeletal injections with the advantage of a lower cost of $0.18 per procedure.

Transplant renal artery stenosis in children: risk factors and outcome after endovascular treatment.

BACKGROUND: Transplant renal artery stenosis (TRAS) is an increasingly recognised cause of post-transplant hypertension. METHODS: We retrospectively analysed 216 paediatric renal recipients transplanted between 2001 and 2011 to assess TRAS prevalence and percutaneous transluminal angioplasty (PTA) efficacy. To assess risk factors, we compared children with TRAS with a propensity score-matched cohort of recipients without TRAS. RESULTS: Of the 216 paediatric patients who were transplanted in the study period, 44 were hypertensive (prevalence 20.3 %) and ten presented with TRAS (prevalence 4.6 %, median age at transplantation 14 years, range 6.78-17.36 years). Hypertensive patients without TRAS were prescribed one to two anti-hypertensive agents, whereas patients with TRAS required one to five medications. In the TRAS group, one recipient presented with vascular complications during surgery, and in three patients the graft had vascular abnormalities. TRAS was detected by Doppler ultrasonography (US) performed due to hypertension in nine of the patients with TRAS, but in the tenth case the TRAS was clinically silent and detected by routine Doppler-US screening. TRAS diagnosis was refined using angio-computed tomography or angio-magnetic resonance imaging. All patients underwent PTA without complications. Significant improvement after PTA was observed in the standard deviation scores for blood pressure [3.2 ± 1.4 (pre-PTA) vs. 1.04 ± 0.8 (post-PTA); p = 0.0006) and graft function [creatinine clearance: 69 ± 17.08 (pre-PTA) vs. 80.7 ± 21.5 ml/min/1.73 m(2) (post-PTA); p = 0.006] We observed no significant differences between the two cohorts for cold ischaemia time, recipient/donor weight ratio, delayed graft function, cytomegalovirus infections and acute rejection episodes. CONCLUSIONS: Our study reports a low but significant TRAS prevalence among the paediatric patients who were transplanted at our centre in the study period and confirms that PTA is an effective and safe therapeutic option in paediatric renal transplant recipients. Known risk factors do not appear to be related to the development of TRAS.

Paediatric bone lesions: diagnostic accuracy of imaging correlation and CT-guided needle biopsy for differentiating benign from malignant lesions.

OBJECTIVE: To determine the sensitivity, specificity and accuracy of CT-guided needle biopsy (CT-NB) for distinguishing benign and malignant lesions in children with suspected primary bone tumours, and to assess the correlation between imaging diagnosis and final diagnosis. METHODS: Retrospective review of children who underwent CT-NB of a suspected primary bone tumour between October 2016 and October 2019. Data collected included anatomical location, imaging diagnosis, type of needle, type of biopsy sample, CT-NB diagnosis, final diagnosis and post-procedural complications. The final diagnosis was established based on surgical histology or clinical/imaging follow-up. RESULTS: 125 patients met the inclusion criteria (68M, 57F: mean age 11 years; range 10 months-18 years). Biopsy was performed using a 10 cm Jamshidi needle (10G n = 96; 13 G n = 8); 14G Tru-Cut needle (n = 18); 14G Temno needle (n = 3). The commonest anatomical locations were the femur (n = 40), tibia (n = 25) and humerus (n = 16), while the commonest diagnoses were osteosarcoma (n = 35), CRMO (n = 15) and LCH (n = 14). A benign tumour was correctly identified on imaging in 100% of cases, and a malignant tumour in 95.8%. Sensitivity, specificity and diagnostic accuracy of CT-NB for distinguishing malignant from benign lesions were 98%, 100 and 99%. Of 24 indeterminate biopsy results, all that had a non-aggressive radiological appearance were benign. No immediate complications were recorded. CONCLUSION: CT-NB represents a safe and very effective tool for differentiating benign and malignant lesions in children presenting with a suspected primary bone tumour. Suspected radiological diagnosis plays a pivotal role in the management of indeterminate biopsy results. ADVANCES IN KNOWLEDGE: Paediatric bone tumours pose a significant diagnostic and therapeutic challenge. The interpretation of the imaging findings is essential for the successful management of indeterminate histological results.

Lower limb muscle injuries: The good, the bad and the ugly.

Injuries to the lower limb muscles are a common cause of absence from training and competition in athletes. The different muscular groups of the thigh and leg are involved in various activities with kicking and sprinting being responsible for the largest number of injuries. The muscle acts on bone through the tendon and the fascia. The failure of one or more of these structures results in various degrees of loss of function of the muscle(s) involved. Usually, the point of weakness is the interface between different structures with different elastic properties (myofascial, myotendinous, avulsion). Diagnostic imaging is best performed by MRI that provides valuable information about the severity of the injury and its anatomical extent. In this article, we will review the MRI features of muscle injuries which can be used to guide return to play. We will emphasize the clinical implications of the MRI findings by dividing the muscle injuries into three categories "The Good, The Bad and The Ugly" to help the clinician in the planning of the most appropriate rehabilitation strategy.

The impact of age and sex on the diagnosis of intrinsic rectus femoris masses: A single centre experience.

Various pathologies may affect the rectus femoris manifesting as an enlargement of the muscle belly. These include traumatic, inflammatory and neoplastic conditions. We did a retrospective study to provide simple guidelines that will serve as an aid for the clinician in order to diagnose lesions presenting as a mass in the rectus femoris. 81 patients with rectus femoris mass referred to tertiary oncology centre were included in the study. The most common lesions were traumatic and benign tumours. In males, traumatic was commonest (90%) and in female over 40 years, 60% were benign and traumatic.

Metaphyseal burst sign: A secondary sign on MRI of subchondral insufficiency fracture of the knee.

INTRODUCTION: To describe a novel secondary sign of subchondral insufficiency fracture of the knee, metaphyseal burst sign (soft tissue oedema in the meta-epiphyseal region of the affected condyle). METHODS: An electronic database research of 7926 knee MRI examinations was performed. Forty-eight scans were included in the study. The diagnosis of subchondral insufficiency fracture (SIF) was confirmed in a consensus review by one fellowship trained musculoskeletal (MSK) radiologist and one radiology fellow. The presence of metaphyseal burst sign was evaluated in the cohort. RESULTS: Forty-one patients were included in the study (21 males, 20 females). The mean age was 61.5 years (range 41-80 years). The anatomical location was medial femoral condyle (n = 28), the lateral femoral condyle (n = 5) and medial tibial condyle (n = 8). The metaphyseal burst sign was present in 45 of the 48 scans reviewed. The average craniocaudal length of the soft tissue oedema defined as metaphyseal burst sign was 7 cm (range 10.5 to 4.5). CONCLUSION: The metaphyseal burst sign is an early, indirect sign of SIF.