The smoke sign: a secondary sign of unsuspected acute pectoralis major tendon injury on routine shoulder MRI.

OBJECTIVE: To study the diagnostic utility of the "smoke sign" to detect unsuspected acute pectoralis major tendon injury on routine shoulder MRI. MATERIALS AND METHODS: Retrospective study of 52 shoulder MRI in patients with (38) and without (14) acute pectoralis major injury confirmed on imaging. Two readers independently reviewed shoulder MRI for the presence of the "smoke sign"-feathery soft tissue edema lateral or anterior to short head biceps/coracobrachialis on fluid-sensitive coronal-oblique and sagittal-oblique images, respectively. RESULTS: The smoke sign was present on shoulder MRI in 24/24 (100%) humeral avulsions, 4/4 (100%) tendon tears, 4/8 (50%) of myotendinous junction injuries, and 0/2 (0%) intramuscular injuries. The smoke sign was present in 0/14 examinations without acute pectoralis major injury. CONCLUSION: While dedicated pectoralis MRI remains the preferred method for imaging pectoralis injury, the "smoke sign" can serve as an easy to recognize finding on routine shoulder MRI that can raise the suspicion of an acute pectoralis major tendon injury. Its detection should prompt evaluation of the pectoralis major tendon and recommendation for dedicated imaging to confirm and evaluate the full extent of injury.

MRI of the Fingers: An Update.

OBJECTIVE. The purpose of this article is to review the general guidelines for MRI of the finger and emphasize normal finger anatomy as it relates to abnormalities and injuries. CONCLUSION. Advanced imaging, particularly MRI, is increasingly relied on to make the diagnosis and guide management of finger injuries. It is incumbent on radiologists to understand the complex anatomy of the fingers as well as to be familiar with common injuries and aspects of injuries that affect management in order to meaningfully contribute to patient care.

Drill-Assisted Biopsy of the Axial and Appendicular Skeleton: Safety, Technical Success, and Diagnostic Efficacy.

The purpose of this study was to evaluate the safety, technical success rate, and diagnostic efficacy of drill-assisted axial and appendicular bone biopsies. During a 3-y period, 703 drill-assisted biopsies were performed. The cohort included 54.2% men, with a mean age of 57.6 y ± 17.1. Median lesion volume was 10.9 mL (interquartile range, 3.4-30.2 mL). Lesions were lytic (31.7%), sclerotic (21.2%), mixed lytic and sclerotic (27.7%), or normal radiographic bone quality (19.3%). No complications were reported. The technical biopsy success rate was 99.9%. Crush artifact was present in 5.8% of specimens submitted for surgical pathologic examination, and 2.1% of specimens were inadequate for histologic evaluation.

Percutaneous Image-Guided Cryoablation of Musculoskeletal Metastases: Pain Palliation and Local Tumor Control.

PURPOSE: To evaluate the safety and effectiveness of cryoablation of musculoskeletal metastases in terms of achieving pain palliation and local tumor control. MATERIALS AND METHODS: A retrospective review was performed of 92 musculoskeletal metastases in 56 patients treated with percutaneous image-guided cryoablation. Mean age of the cohort was 53.9 y ± 15.1, and cohort included 48% (27/56) men. Median tumor volume was 13.0 cm3 (range, 0.5-577.2 cm3). Indications for treatment included pain palliation (41%; 38/92), local tumor control (15%; 14/92), or both (43%; 40/92). Concurrent cementoplasty was performed after 28% (26/92) of treatments. RESULTS: In 78 tumors treated for pain palliation, median pain score before treatment was 8.0. Decreased median pain scores were reported 1 day (6.0; P < .001, n = 62), 1 week (5.0; P < .001, n = 70), 1 month (5.0; P < .001, n = 63), and 3 months (4.5; P = .01, n = 28) after treatment. The median pain score at 6-month follow-up was 7.5 (P = .33, n = 11). Radiographic local tumor control rates were 90% (37/41) at 3 months, 86% (32/37) at 6 months, and 79% (26/33) at 12 months after treatment. The procedural complication rate was 4.3% (4/92). The 3 major complications included 2 cases of hemothorax and 1 transient foot drop. CONCLUSIONS: Cryoablation is an effective treatment for palliating painful musculoskeletal metastases and achieving local tumor control.

Combination acetabular radiofrequency ablation and cementoplasty using a navigational radiofrequency ablation device and ultrahigh viscosity cement: technical note.

BACKGROUND: Percutaneous radiofrequency ablation and cementoplasty is an alternative palliative therapy for painful metastases involving axial load-bearing bones. This technical report describes the use of a navigational radiofrequency probe to ablate acetabular metastases from an anterior approach followed by instillation of ultrahigh viscosity cement under CT-fluoroscopic guidance. MATERIALS AND METHODS: The tumor ablation databases of two institutions were retrospectively reviewed to identify patients who underwent combination acetabular radiofrequency ablation and cementoplasty using the STAR Tumor Ablation and StabiliT Vertebral Augmentation Systems (DFINE; San Jose, CA). Pre-procedure acetabular tumor volume was measured on cross-sectional imaging. Pre- and post-procedure pain scores were measured using the Numeric Rating Scale (10-point scale) and compared. Partial pain improvement was categorically defined as ≥ 2-point pain score reduction. Patients were evaluated for evidence of immediate complications. Electronic medical records were reviewed for evidence of delayed complications. RESULTS: During the study period, 12 patients with acetabular metastases were treated. The median tumor volume was 54.3 mL (range, 28.3-109.8 mL). Pre- and post-procedure pain scores were obtained from 92% (11/12) of the cohort. The median pre-procedure pain score was 8 (range, 3-10). Post-procedure pain scores were obtained 7 days (82%; 9/11), 11 days (9.1%; 1/11) or 21 days (9.1%; 1/11) after treatment. The median post-treatment pain score was 3 (range, 1-8), a statistically significant difference compared with pre-treatment (P = 0.002). Categorically, 73% (8/11) of patients reported partial pain relief after treatment. No immediate symptomatic complications occurred. Three patients (25%; 3/12) were discharged to hospice within 1 week of treatment. No delayed complications occurred in the remaining 75% (9/12) of patients during median clinical follow-up of 62 days (range, 14-178 days). CONCLUSIONS: Palliative percutaneous acetabular radiofrequency ablation and cementoplasty can be feasibly performed from an anterior approach using a navigational ablation probe and ultrahigh viscosity cement instilled under CT-fluoroscopic guidance.

IL-17A inhibits the expansion of IL-17A-producing T cells in mice through "short-loop" inhibition via IL-17 receptor.

IL-23 and IL-17A regulate granulopoiesis through G-CSF, the main granulopoietic cytokine. IL-23 is secreted by activated macrophages and dendritic cells and promotes the expansion of three subsets of IL-17A-expressing neutrophil-regulatory T (Tn) cells; CD4(-)CD8(-)alphabeta(low), CD4(+)CD8(-)alphabeta(+) (Th17), and gammadelta(+) T cells. In this study, we investigate the effects of IL-17A on circulating neutrophil levels using IL-17R-deficient (Il17ra(-/-)) mice and Il17ra(-/-)Itgb2(-/-) mice that lack both IL-17R and all four beta(2) integrins. IL-17R deficiency conferred a reduction in neutrophil numbers and G-CSF levels, as did Ab blockade against IL-17A in wild-type mice. Bone marrow transplantation revealed that IL-17R expression on nonhemopoietic cells had the greatest effects on regulating blood neutrophil counts. Although circulating neutrophil numbers were reduced, IL-17A expression, secretion, and the number of IL-17A-producing Tn cells were elevated in Il17ra(-/-) and Il17ra(-/-)Itgb2(-/-) mice, suggesting a negative feedback effect through IL-17R. The negative regulation of IL-17A-producing T cells and IL-17A and IL-17F gene expression through the interactions of IL-17A or IL-17F with IL-17R was confirmed in splenocyte cultures in vitro. We conclude that IL-17A regulates blood neutrophil counts by inducing G-CSF production mainly in nonhemopoietic cells. IL-17A controls the expansion of IL-17A-producing Tn cell populations through IL-17R.

Radiographic Local Tumor Control and Pain Palliation of Sarcoma Metastases within the Musculoskeletal System with Percutaneous Thermal Ablation.

PURPOSE: To evaluate the effectiveness of percutaneous image-guided thermal ablation in achieving local tumor control and pain palliation of sarcoma metastases within the musculoskeletal system. MATERIALS AND METHODS: Retrospective review of 64 sarcoma metastases within the musculoskeletal system in 26 women and 15 men (total = 41) treated with ablation between December 2011 and August 2016 was performed. Mean age of the cohort was 42.9 years ± 16.0 years. Two subgroups were treated: oligometastatic disease (n = 13) and widely metastatic disease (n = 51). A variety of sarcoma histologies were treated with average tumor volume of 42.5 cm3 (range 0.1-484.7 cm3). Pain scores were recorded before and 4 weeks after therapy for 59% (38/64) of treated lesions. Follow-up imaging was evaluated for local control and to monitor sites of untreated disease as an internal control. Fifty-eight percent (37/64) were lost to imaging follow-up at varying time points over a year. Complication rate was 5% (3/64; one minor and two major events). RESULTS: One-year local tumor control rates were 70% (19/27) in all patients, 67% (12/18) in the setting of progression of untreated metastases, and 100% (10/10) in the setting of oligometastatic disease. Median pain scores decreased from 8 (interquartile range 5.0-9.0) to 3 (interquartile range 0.1-4.0) 1 month after the procedure (P < 0.001). CONCLUSION: Image-guided percutaneous ablation is an effective option for local tumor control and pain palliation of metastatic sarcomas within the musculoskeletal system. Treatment in the setting of oligometastatic disease offers potential for remission. LEVEL OF EVIDENCE: Level 4, Retrospective Review.