Characterization of indeterminate soft tissue masses referred for biopsy: What is the added value of contrast imaging at 3.0 tesla?

PURPOSE: To assess the added value of contrast-enhanced (CE) MR sequences (static CE-MR sequences, dynamic CE-MR sequences) to noncontrast enhanced MR sequences (non-CE-MR sequences) including T1, fluid-sensitive, and diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping for characterizing "indeterminate" soft tissue masses (STMs) as benign or malignant. MATERIALS AND METHODS: Thirty-nine patients with indeterminate STMs (27 benign, 12 malignant) underwent 3 Tesla MRI with conventional non-CE-MR sequences (T1-weighted, fluid-sensitive), DWI (b-values 50, 400, 800, ADC mapping), dynamic CE-MR sequences (7-s time resolution), and static CE-MR sequences. Two readers independently reviewed imaging in four sessions (conventional non-CE-MR sequences alone, conventional+DWI/ADC, conventional+DWI/ADC+static CE-MR sequences, conventional+DWI/ADC+static CE-MR sequences dynamic CE-MR sequences). Readers recorded the potential of malignancy at each session; reader diagnostic performance (receiver operating characteristics analysis) and inter-observer variability (weighted kappa [k]) were determined. RESULTS: Diagnostic performance for distinguishing benign and malignant STMs was highest with the addition of dynamic CE-MR sequences (reader 1, area under the curve [AUC] 0.91; reader 2, AUC 0.88). The diagnostic performance of static CE-MR sequences (reader 1, AUC 0.86; reader 2, AUC 0.84) was not superior to non-CE-MR sequences with DWI (reader 1, AUC 0.88; reader 2, AUC 0.8). Interobserver agreement was: k = 0.82 (static CE-MRI), k = 0.79 (dynamic CE-MRI), k = 0.53 (non-CE-MR sequences without DWI), and k = 0.63 (with DWI). CONCLUSION: Non-CE-MR sequences offer similar diagnostic performance to imaging with the addition of static CE-MR sequences, but their interobserver reliability is lower. The addition of dynamic CE-MR sequences offers the higher diagnostic performance for distinguishing benign and malignant indeterminate STMs. LEVEL OF EVIDENCE: 3 J. Magn. Reson. Imaging 2017;45:390-400.

MDCT of hand and wrist infections: emphasis on compartmental anatomy.

Hand and wrist infections can present with a spectrum of manifestations ranging from cellulitis to deep-space collections. The various infectious processes can be categorised as superficial or deep infections based on their respective locations relative to the tendons. Superficial hand infections are located superficial to the tendons and are comprised of cellulitis, lymphangitis, paronychia, pulp-space infections, herpetic whitlow, and include volar as well as dorsal subcutaneous abscesses. Deep hand infections are located deep to the tendon sheaths and include synovial space infections, such as infectious tenosynovitis, deep fascial space infections, septic arthritis, necrotising fasciitis, and osteomyelitis. Knowledge of hand and wrist compartmental anatomy is essential for the accurate diagnosis and management of hand infections. Although early and superficial infections of the hand may respond to non-surgical management, most hand infections are surgical emergencies. Multidetector computed tomography (MDCT), with its muliplanar reformation (MPR) and three-dimensional (3D) capabilities, is a powerful tool in the emergency setting for the evaluation of acute hand and wrist pathology. The clinical and imaging features of hand and wrist infections as evident on MDCT will be reviewed with emphasis on contiguous and closed synovial and deep fascial spaces. Knowledge of hand compartmental anatomy enables accurate characterisation of the infectious process and localise the extent of disease in the acute setting.

MRI characteristics associated with high-grade myxoid liposarcoma.

AIM: To identify magnetic resonance imaging (MRI) features differentiating high-grade (>5% round-cell component) from low-grade myxoid liposarcomas (LPS) (≤5% round-cell component). MATERIALS AND METHODS: Informed consent was waived. Patients with myxoid LPS and MRI before biopsy, neoadjuvant therapy, and surgery were included retrospectively. High-grade components were recorded from histological specimens by a pathologist (24 years of experience). Images were evaluated by a senior radiologist (>12 years of experience) for tumour size, location, tissue layer, and MRI features (signal intensity, heterogeneity, margin, and perilesional characteristics). Descriptive statistics, Fisher's exact test to identify associations with a round-cell component, and multivariate logistic regression to identify independent predictors of high-grade tumours were used. RESULTS: Thirty-one patients (16 women [mean 51.1 years; range 19-79 years] and 15 men [mean 45.5 years; range 18-95 years]) with myxoid LPS (23 low-grade, eight high-grade) were included. All high-grade lesions had lipid signal, a peritumoural capsule and peritumoural contrast enhancement, and more commonly exhibited heterogeneous signal; however, the average size of ≥10 cm was the strongest independent indicator of high-grade status (odds ratio [OR], 14.6; 95% confidence interval [CI]: 1.6, 131). CONCLUSION: Size ≥10 cm is most strongly associated with high-grade myxoid LPS (round-cell component >5%). Other features possibly differentiating high-grade from low-grade status include lesion margin, lipid signal, and perilesional characteristics.

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.

Association of mucoid degeneration of anterior cruciate ligament with knee meniscal and cartilage damage.

OBJECTIVE: To assess the prevalence of anterior cruciate ligament (ACL) mucoid degeneration in patients referred for routine knee magnetic resonance (MR) imaging, and its association with age and structural joint damage. METHOD: Four independent radiologists assessed 413 consecutive knee MR examinations for the presence of a normal or ruptured ACL, or ACL mucoid degeneration. Knees with ACL mucoid degeneration were frequency matched by age, sex, and MR field strength with consecutive control knees with a normal ACL (1:2 ratio). Differences in meniscal and cartilage damage of the tibiofemoral compartments, as determined by the Whole-Organ MR Imaging Score (WORMS) system, were compared by Mann-Whitney U tests. Multivariable logistic regression analysis identified the association of ACL mucoid degeneration with severe MTFC cartilage damage (WORMS≥5). RESULTS: Patients with ACL mucoid degeneration (n = 36; 36% males; median age 55.5 years, range: 26-81) were older than patients with a normal (P < 0.001) or ruptured ACL (P < 0.001), without sex predilection (P = 0.76), and were more frequently diagnosed at 3 T (12%) compared to 1.5 T (2%). Knees with ACL mucoid degeneration had statistically significantly more medial meniscal (P < 0.001) and central and posterior medial tibiofemoral compartment (MTFC) cartilage (P < 0.001) damage compared with control knees (n = 72), but there were no differences in patients ≤50 years (P = 0.09 and 0.32, respectively). In multivariable logistic regression, severe MTFC cartilage damage (WORMS≥5) was significantly associated with ACL mucoid degeneration (odds ratio 4.09, 95% confidence interval 1.29-12.94, P = 0.016). CONCLUSION: There is a strong association between ACL mucoid degeneration and cartilage damage in the central and posterior MTFC, especially in patients >50 years.

Assessment of image quality in soft tissue and bone visualization tasks for a dedicated extremity cone-beam CT system.

OBJECTIVE: To assess visualization tasks using cone-beam CT (CBCT) compared to multi-detector CT (MDCT) for musculoskeletal extremity imaging. METHODS: Ten cadaveric hands and ten knees were examined using a dedicated CBCT prototype and a clinical multi-detector CT using nominal protocols (80 kVp-108mAs for CBCT; 120 kVp- 300 mAs for MDCT). Soft tissue and bone visualization tasks were assessed by four radiologists using five-point satisfaction (for CBCT and MDCT individually) and five-point preference (side-by-side CBCT versus MDCT image quality comparison) rating tests. Ratings were analyzed using Kruskal-Wallis and Wilcoxon signed-rank tests, and observer agreement was assessed using the Kappa-statistic. RESULTS: Knee CBCT images were rated "excellent" or "good" (median scores 5 and 4) for "bone" and "soft tissue" visualization tasks. Hand CBCT images were rated "excellent" or "adequate" (median scores 5 and 3) for "bone" and "soft tissue" visualization tasks. Preference tests rated CBCT equivalent or superior to MDCT for bone visualization and favoured the MDCT for soft tissue visualization tasks. Intraobserver agreement for CBCT satisfaction tests was fair to almost perfect (κ ~ 0.26-0.92), and interobserver agreement was fair to moderate (κ ~ 0.27-0.54). CONCLUSION: CBCT provided excellent image quality for bone visualization and adequate image quality for soft tissue visualization tasks. KEY POINTS: • CBCT provided adequate image quality for diagnostic tasks in extremity imaging. • CBCT images were "excellent" for "bone" and "good/adequate" for "soft tissue" visualization tasks. • CBCT image quality was equivalent/superior to MDCT for bone visualization tasks.

Glenoid notch MRI findings do not predict normal variants of the anterior and superior labrum.

AIM: To determine (1) the relationship of a glenoid notch to the presence of a normal labral variant in the anterior-superior glenoid labrum; (2) the inter- and intra-observer reliability of recognising a glenoid notch; and (3) whether magnetic resonance arthrography (MRA) is more reliable than non-contrast magnetic resonance imaging (MRI) in visualising a glenoid notch. MATERIALS AND METHODS: From 1995 through 2010, 104 patients underwent MRI or MRA before diagnostic shoulder arthroscopy by the senior author. Five blinded musculoskeletal radiologists independently read the images twice to evaluate for the presence or absence of a glenoid notch. Fifty-nine (57%) patients had normal anterior-superior labral variants. The authors calculated the relationship of the readings to the arthroscopically determined presence or absence of a normal labral variant and the reading's diagnostic performance and rater reliability. RESULTS: On average, 38% (range 9-65%) of the glenoid scans were read as notched. The sensitivity, specificity, positive predictive value, and negative predictive value of the notch relative to the presence of a normal variant were 43.1%, 71.2%, 70.2%, and 48% versus 44.3%, 77.5%, 79.4%, and 56.1% for MRI and MRA, respectively. The overall average intra-observer κ-values were 0.438 (range 0.203-0.555) and 0.346 (range -0.102 to 0.570) for MRI and MRA, respectively. The average interobserver intra-class correlation coefficient reliability values were 0.730 (range 0.693-0.760) and 0.614 (range 0.566-0.662) for MRI and MRA, respectively. CONCLUSIONS: A notched glenoid on MRI lacks sufficient diagnostic performance and rater reliability for the clinical detection and prediction of normal anterior-superior labral variants.

Gradient-echo in-phase and opposed-phase chemical shift imaging: role in evaluating bone marrow.

Chemical shift imaging (CSI) provides valuable information for assessing the bone marrow, while adding little to total examination time. In this article, we review the uses of CSI for evaluating bone marrow abnormalities. CSI can be used for differentiating marrow-replacing lesions from a range of non-marrow-replacing processes, although the sequence is associated with technical limitations and pitfalls. Particularly at 3 T, susceptibility artefacts are prevalent, and optimal technical parameters must be implemented with appropriate choices for echo times.

Chemical shift imaging at 3 Tesla: effect of echo time on assessing bone marrow abnormalities.

OBJECTIVE: Our purpose is to test the effect of varied in-phase (IP) and opposed-phase (OP) sequence order on characterizing marrow signal changes at 3T. MATERIALS AND METHODS: The study was HIPAA compliant and IRB approved. Informed consent was waived. At 3T, IP and OP sequences were acquired in three patients with biopsy-proven osteosarcomas, using two methods: approach 1 (OP acquisition before IP acquisition) and approach 2 (OP after IP). Signal intensity (SI) measurements in 12 locations of biopsy-proven osteosarcoma and in six locations with normal bone marrow were performed independently by two experienced musculoskeletal radiologists. The signal intensity ratio (SIR) was measured within the marrow where there was T1 signal lower than skeletal muscle. A SIR < 20 % on the OP compared with IP imaging was considered positive for marrow replacement, while SIR > = 20 % was considered negative. Interobserver agreement was measured by the Lin concordance correlation coefficient (CCC). RESULTS: In 75 % (18/24) of locations within the biopsy-proven tumors, the SIR was >20 % (SI drop more than 20 % in OP compared to IP) using approach 2 and in 100 % (24/24) of the locations the SIR was <20 % (SI drop less than 20 % in OP compared to IP) using approach 1, indicating a high percentage of false-negative results by approach 2, and no false-negative results with approach 1. There was good agreement between observer measurement (CCC = 0.96). CONCLUSIONS: At 3T, the OP sequence should be acquired prior to the IP sequence, because susceptibility artifacts on a later-acquired OP sequence may lead to an erroneous interpretation of marrow signal abnormalities.

Magnetic resonance imaging of pancreatic adenocarcinoma.

BACKGROUND: Magnetic resonance imaging (MRI) should be considered essential to the presurgical evaluation of pancreatic adenocarcinoma, to accurately detect resectable lesions and to spare patients with non-resectable tumors the morbidity, mortality, and expense of unnecessary surgery. This article is a review of the MRI characteristics of pancreatic adenocarcinoma, the features that determine its resectability, and the optimal MR sequences needed for its effective evaluation. The role of MRI imaging is contrasted with other imaging and invasive modalities for the diagnosis and staging of pancreatic adenocarcinoma.

Conventional and functional MR imaging of peripheral nerve sheath tumors: initial experience.

BACKGROUND AND PURPOSE: Differentiating benign from malignant peripheral nerve sheath tumors can be very challenging using conventional MR imaging. Our aim was to test the hypothesis that conventional and functional MR imaging can accurately diagnose malignancy in patients with indeterminate peripheral nerve sheath tumors. MATERIALS AND METHODS: This institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study retrospectively reviewed 61 consecutive patients with 80 indeterminate peripheral nerve sheath tumors. Of these, 31 histologically proved peripheral nerve sheath tumors imaged with conventional (unenhanced T1, fluid-sensitive, contrast-enhanced T1-weighted sequences) and functional MR imaging (DWI/apparent diffusion coefficient mapping, dynamic contrast-enhanced MR imaging) were included. Two observers independently assessed anatomic (size, morphology, signal) and functional (ADC values, early arterial enhancement by dynamic contrast-enhanced MR) features to determine interobserver agreement. The accuracy of MR imaging for differentiating malignant from benign was also determined by receiver operating characteristic analysis. RESULTS: Of 31 peripheral nerve sheath tumors, there were 9 malignant (9%) and 22 benign ones (81%). With anatomic sequences, average tumor diameter (6.3 ± 1.8 versus 3.9 ± 2.3 mm, P = .009), ill-defined/infiltrative margins (77% versus 32%; P = .04), and the presence of peritumoral edema (66% versus 23%, P = .01) were different for malignant peripheral nerve sheath tumors and benign peripheral nerve sheath tumors. With functional sequences, minimum ADC (0.47 ± 0.32 × 10(-3) mm(2)/s versus 1.08 ± 0.26 × 10(-3) mm(2)/s; P < .0001) and the presence of early arterial enhancement (50% versus 11%; P = .03) were different for malignant peripheral nerve sheath tumors and benign peripheral nerve sheath tumors. The minimum ADC (area under receiver operating characteristic curve was 0.89; 95% confidence interval, 0.73-0.97) and the average tumor diameter (area under the curve = 0.8; 95% CI, 0.66-0.94) were accurate in differentiating malignant peripheral nerve sheath tumors from benign peripheral nerve sheath tumors. With threshold values for minimum ADC ≤ 1.0 × 10(-3) mm(2)/s and an average diameter of ≥4.2 cm, malignancy could be diagnosed with 100% sensitivity (95% CI, 66.4%-100%). CONCLUSIONS: Average tumor diameter and minimum ADC values are potentially important parameters that may be used to distinguish malignant peripheral nerve sheath tumors from benign peripheral nerve sheath tumors.

Complications of rotator cuff surgery-the role of post-operative imaging in patient care.

When pain or disability occurs after rotator cuff surgery, post-operative imaging is frequently performed. Post-operative complications and expected post-operative imaging findings in the shoulder are presented, with a focus on MRI, MR arthrography (MRA) and CT arthrography. MR and CT techniques are available to reduce image degradation secondary to surgical distortions of native anatomy and implant-related artefacts and to define complications after rotator cuff surgery. A useful approach to image the shoulder after surgery is the standard radiography, followed by MRI/MRA for patients with low "metal presence" and CT for patients who have a higher metal presence. However, for the assessment of patients who have undergone surgery for rotator cuff injuries, imaging findings should always be correlated with the clinical presentation because post-operative imaging abnormalities do not necessarily correlate with symptoms.

Characterization of peripheral nerve sheath tumors with 3T proton MR spectroscopy.

BACKGROUND AND PURPOSE: The characterization of peripheral nerve sheath tumors is challenging. The purpose here was to investigate the diagnostic value of quantitative proton MR spectroscopy at 3T for the characterization of peripheral nerve sheath tumors as benign or malignant, compared with PET. MATERIALS AND METHODS: Twenty participants with 24 peripheral nerve sheath tumors underwent MR spectroscopy by use of a point-resolved sequence (TE, 135 ms). Six voxels were placed in 4 histologically proven malignant peripheral nerve sheath tumors and 22 voxels in 20 benign peripheral nerve sheath tumors (9 histologically proven, 11 with documented stability). The presence or absence of a trimethylamine signal was evaluated, the trimethylamine concentration estimated by use of phantom replacement methodology, and the trimethylamine fraction relative to Cr measured. MR spectroscopy results for benign and malignant peripheral nerve sheath tumors were compared by use of a Mann-Whitney test, and concordance or discordance with PET findings was recorded. RESULTS: In all malignant tumors and in 9 of 18 benign peripheral nerve sheath tumors, a trimethylamine peak was detected, offering the presence of trimethylamine as a sensitive (100%), but not specific (50%), marker of malignant disease. Trimethylamine concentrations (2.2 ± 2.8 vs 6.6 ± 5.8 institutional units; P < .049) and the trimethylamine fraction (27 ± 42 vs 88 ± 22%; P < .012) were lower in benign than malignant peripheral nerve sheath tumors. A trimethylamine fraction threshold of 50% resulted in 100% sensitivity (95% CI, 58.0%-100%) and 72.2% (95% CI, 59.5%-75%) specificity for distinguishing benign from malignant disease. MR spectroscopy and PET results were concordant in 12 of 16 cases, (2 false-positive results for MR spectroscopy and PET each). CONCLUSIONS: Quantitative measurement of trimethylamine concentration by use of MR spectroscopy is feasible in peripheral nerve sheath tumors and shows promise as a method for the differentiation of benign and malignant lesions. Trimethylamine presence within a peripheral nerve sheath tumor is a sensitive marker of malignant disease, but quantitative measurement of trimethylamine content is required to improve specificity.