Position paper on magnetic resonance imaging protocols in the musculoskeletal system (excluding the spine) by the Italian College of Musculoskeletal Radiology.

Magnetic resonance imaging (MRI) is a pivotal radiological examination in clinical practice, being widely applied for musculoskeletal examinations. In this setting, strict adherence to standardized protocol is crucial to increase diagnostic performance and minimize variability among different diagnostic centres and readers. The aim of this paper is to provide standardized technical recommendations for musculoskeletal MRI scans proposed by the Italian College of Musculoskeletal Radiology. These recommendations are designed to give a uniform application of MRI protocols over the national territory, to increase reproducibility and improve diagnostic performance.

Intra-arterial infusion of 5-fluorouracil, leucovorin, epirubicin and carboplatin (FLEC regimen) in unresectable pancreatic cancer: results of a ten-year experience.

UNLABELLED: The final results of a new regimen given intra-arterially for unresectable pancreatic cancer (UPC) are presented. PATIENTS AND METHODS: From January 1994 to January 2006, 5-fluorouracil 1,000 mg/m2, leucovorin 100 mg/m2, epirubicin 60 mg/m2 and carboplatin 300 mg/m2 were administered every 3 weeks into the celiac axis (CA) angiografically (FLEC regimen) to 211 patients with UPC. RESULTS: Seven hundred and sixty-four cycles were administered. Grade 3-4 hematological toxicity was observed in 24%; ematemesis in 4%; grade 3 gastrointestinal toxicity in 3%; grade 3 alopecia in 15%. One sudden death, a pre-infarction angina and a transitory ischemic attack were observed. No complications related to the angiographic procedure took place, but three tunica intima dissections of the iliac artery occurred; 7.6% of patients with partial responses and 50.7% with stable disease were observed. Two hundred and one patients have died; median overall survival was 9.2 months: 10.5 and 6.6 for stage III and IV, respectively. CONCLUSION: The FLEC regimen given intra-arterially is well-tolerated and effective in patients with UPC.

Percutaneous CT-guided vertebroplasty in the management of osteoporotic fractures and dorsolumbar metastases.

Percutaneous vertebroplasty (PVP) is a minimally invasive, image-guided procedure consisting of an injection of acrylic cement into a vertebral body to reinforce the compressed segment and achieve pain relief. The use of PVP is a minimally invasive option in the treatment of osteoporotic or metastatic vertebral collapses. Our personal experience, using a CT-guided technique, confirms the efficacy and safety of PVP with a lower risk for complications compared with conventional fluoroscopic approaches because of a precise placement of the instruments in the vertebral body and an early detection of small cement leakages.

Alignment and articular orientation of lower limbs: manual vs computer-aided measurements on digital radiograms.

PURPOSE: To compare the manual measurements of lower limbs on digital images with those obtained with dedicated software. MATERIALS AND METHODS: Forty patients with a clinical suspicion of lower limb deformity were enrolled. Eighty digital radiographs were produced with a remote-controlled radiography system (Philips Omnidiagnost). The measurements were taken separately by an Orthopaedic Surgeon and by a Radiologist, by hand and with the aid of software, respectively. Five parameters were assessed: femoral length, tibial length, distal-medial femoral angle, proximal-medial tibial angle and tibial-femoral angle. The statistical analysis of the comparison was based on Student's t-test. The inter-observer variability of the methods, manual and computer-aided, was evaluated with Fisher's F-test on a sample of measurements (20 lower limbs), taken by 5 different Orthopaedic Surgeons and Radiologists, respectively. RESULTS: There were no statistically significant differences between the measurements taken with the manual and computer-aided methods (p<0.05). The overall reproducibility of both methods was similar; conversely, the separate evaluation of angles and lengths showed that the computer-aided method was less variable in the measurement of angles and a little more variable in the measurement of lengths than the manual method. CONCLUSIONS: The computer-aided evaluation of the alignment and articular orientation parameters of lower limbs is as accurate and reliable as the traditional manual method, but is faster and allows better-quality images.

MRI versus scintigraphy with 99mTc-HMPAO-labelled granulocytes in the diagnosis of bone infection.

PURPOSE: To assess the reliability of MRI and scintigraphy with 99mTc-HMPAO-labelled granulocytes in the diagnosis of bone infection. MATERIALS AND METHODS: Between November 2001 and November 2003, 25 patients (16 men and 9 women; age range 22-72 years; mean age 48 years) with suspected bone infection were evaluated. The lower limbs were more frequently involved (20/25 cases). MRI (T1 and T2-w sequences, both with and without fat suppression; T1-w fat-suppressed sequence after Gadolinium administration) and scintigraphy with 99mTc-HMPAO-labelled granulocytes were performed in all patients; the study was performed 30 min, 150 min and 24 h after the injection of 99mTc labelled autologous granulocytes. The maximum interval between MRI and scintigraphy was 15 days. The diagnosis was confirmed surgically (18/25 cases) or by clinical follow-up (7/25 cases). RESULTS: In 10/25 cases the clinical suspicion of bone infection was confirmed by MRI, scintigraphy and surgery. In 12/25 cases the clinical suspicion of bone infection was not confirmed either by imaging, surgery (5/12 cases) or follow-up (7/12 cases). In 3/25 cases the results were discordant: in 1/3 cases with chronic osteomyelitis confirmed by MRI and surgery, a false-negative diagnosis was made by scintigraphy. In 2/3 cases with negative MRI diagnoses confirmed by surgery, a false-positive diagnosis was made by scintigraphy owing to the infection of adjacent soft tissues. CONCLUSIONS: MRI is more reliable for the detection and evaluation of the local spread of bone infection. Conversely, when metallic devices causing artefacts on MR images are present, scintigraphy is the preferred alternative modality.

Contribution of imaging to the evaluation of pyomyositis.

PURPOSE: To analyse the fundamental features of each imaging modality with the aim of defining their contribution to the diagnosis of pyomyositis. MATERIALS AND METHODS: We retrospectively reviewed 10 observations collected between 1997 and 2004, 5 of paravertebral muscles and 5 of the muscles of the limbs. Imaging was carried out with US (8/10 observations) and/or CT (9/10 observations), and/or MRI (6/10 observations). The pathogen was isolated in 6/10 observations. RESULTS: The imaging criteria for the detection and characterization of pyomyositis are based on three pathological phases: an invasive phase characterized by inflammatory oedema, a suppurative phase characterised by abscess development, and a late phase featuring the distant spread of the infection. Based on these interpretation criteria, pyomyositis was correctly diagnosed with US in 5/8 observations, with CT in 9/9 observations and with MR in 5/6 observations. Four false-negative cases were found. CONCLUSIONS: Since the clinical symptoms of pyomyositis are often insidious and delayed, an integrated imaging approach may be very useful for diagnosing this condition.

Phase II study of hepatic intraarterial epirubicin and cisplatin, with systemic 5-fluorouracil in patients with unresectable biliary tract tumors.

BACKGROUND: Patients with unresectable biliary tract carcinomas have a very poor prognosis. To improve the efficacy and tolerance of the ECF regimen (epirubicin at a dose of 50 mg/m2, cisplatin at a dose of 60 mg/m2, and 5-fluorouracil [5-FU] at a dose of 200 mg/m2 per day by continuous infusion), the authors designed a novel approach that combined locoregional and systemic chemotherapy with the same agents at the same dosages. METHODS: Thirty consecutive patients with advanced or metastatic biliary tumors were treated with epirubicin at a dose of 50 mg/m2 and cisplatin at a dose of 60 mg/m2 administered as a bolus in the hepatic artery on Day 1, combined with systemic continuous infusion of 5-FU at a dose of 200 mg/m2 per day, from Day 1 to Day 14, every 3 weeks. RESULTS: Tumor sites were the intrahepatic bile ducts in 25 patients and the gallbladder in 5 patients. The overall response rate was 40% (12 of 30 patients), including 1 complete response and 11 partial responses. Stable disease was observed in 12 of 30 patients (40%) and progressive disease in 6 of 30 patients (20%). The median progression-free and overall survival periods were 7.1 and 13.2 months, respectively, and the 1-year and 2-year survival rates were 54% and 20%, respectively. Performance status improved in 9 of 30 patients (30%) and a weight gain of > 7% was observed in 4 of 30 patients (13%). The treatment was well tolerated with minimal hematologic toxicity. The major clinical problem was the deep venous thrombosis related to the central venous catheter, which occurred in 5 patients (17%). CONCLUSIONS: This novel combined locoregional and systemic chemotherapeutic regimen was found to be active and safe for patients with advanced biliary tract carcinoma.

Imaging of bone micro-injuries.

PURPOSE: We evaluated the fundamental signs of each imaging modality to define the role of MRI in identifying and characterizing bone micro-injuries. MATERIALS AND METHODS: We retrospectively reviewed 50 MRI examinations performed after preliminary conventional radiography on 25 stress fractures and 25 insufficiency fractures between 1989 and 2002. The number of lesions identified was 55: 11 were evaluated with CT and 9 with radionuclide bone scan. RESULTS: Although bone micro-injuries have different pathogenetic mechanisms, the final outcome is a cortical and/or spongy bone fissure, followed by repair processes. Conventional x-ray showed the presence of a lesion in 24/55 cases. Radionuclide bone scanning allowed suspicion or confirmation of the lesion in 8/9 cases. MR identified the lesion in all cases. CT allowed recognition of the lesion in 10/11 cases. CONCLUSIONS: When a bone micro-injury is suspected following conventional radiography, MRI is the most sensitive and specific modality able to complete the diagnostic work-up.