Structured request form in musculoskeletal radiology examinations (CONCERTO): results of an expert Delphi consensus-structured radiology request form for correct classification of patients to undergo radiological examinations of the Italian Society of Medical and Interventional Radiology (SIRM), the Italian Society of Rheumatology (SIR) and the Italian Society of Orthopedics and Traumatology (SIOT).

PURPOSE: To describe a Delphi consensus for the realization of a structured radiology request form for patients undergoing musculoskeletal imaging. METHODS: A steering committee (four radiologists, a rheumatologist and an orthopedic surgeon) proposed a form to an expert panel (30 members, ten radiologists, ten rheumatologists and ten orthopedic surgeons). Through an online survey, the panelists voted on their level of agreement with the statements of the form using a 10-point Likert scale (1: no agreement; 10: total agreement) in a three-round process. A combination of two distinct criteria, a mean agreement level ≥ 8 and a percentage of at least 75% of responses with a value ≥ 8, was deemed as acceptable. RESULTS: The form achieved high median ratings in all the assessed key features. During the first round, all items met the threshold to be advanced as unmodified in the next round. Additional proposed items were considered and introduced in the next round (six items in Section 1, five items in Section 2, ten items in Section 3, 11 items in Section 4, six items in Section 5, eight items in Section 6, ten items in Section 7 and eight items in Section 8). Of these items, in round 3, only six reached the threshold to be integrated into the final form. CONCLUSIONS: Implementation of a structured radiology request form can improve appropriateness and collaboration between clinicians and radiologists in musculoskeletal imaging.

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.

Diffusion-weighted imaging for the cellularity assessment and matrix characterization of soft tissue tumour.

PURPOSE: To evaluate whether apparent diffusion coefficient (ADC) of diffusion-weighted imaging (DWI) is able to investigate the histological features of soft tissue tumours. METHODS: We reviewed MRIs of soft tissue tumours performed from 2012 to 2015 to calculate the average ADCs. We included 46 patients (27 male; mean age: 57 years, range 12-85 years) with histologically proven soft tissue tumours (10 benign, 2 intermediate 34 malignant) grouped into eight tumour type classes. An experienced pathologist assigned a semi-quantitative cellularity score (very high, high, medium and low) and tumour grading. The t test, ANOVA and linear regression were used to correlate ADC with clinicopathological data. Approximate receiver operating characteristic curves were created to predict possible uses of ADC to differentiate benign from malignant tumours. RESULTS: There was a significant difference (p < 0.01) in ADCs between these three groups excluding myxoid sarcomas. A significant difference was also evident between the tumour type classes (p < 0.001), grade II and III myxoid lesions (p < 0.05), tumour grading classes (p < 0.001) and cellularity scores classes (p < 0.001), with the lowest ADCs in the very high cellularity. While the linear regression analysis showed a significant relationship between ADC and tumour cellularity (r = 0.590, p ≤ 0.05) and grading (r = 0.437, p ≤ 0.05), no significant relationship was found with age, gender, tumour size and histological subtype. An optimal cut-off ADC value of 1.45 × 10-3 mm2/s with 76.8% accuracy was found to differentiate benign from malignant tumours. CONCLUSIONS: DWI may offer adjunctive information about soft tissue tumours, but its clinical role is still to be defined.

Accuracy and role of contrast-enhanced CT in diagnosis and surgical planning in 88 soft tissue tumours of extremities.

OBJECTIVES: Soft tissue tumours (STT) require accurate diagnosis in order to identify potential malignancies. Preoperative planning is fundamental to avoid inadequate treatments. The role of contrast-enhanced computed tomography (CT) for local staging remains incompletely assessed. Aims of the study were to evaluate CT accuracy in discriminating active from aggressive tumours compared to histology and evaluate the role of CT angiography (CTA) in surgical planning. MATERIALS AND METHODS: This retrospective cohort series of 88 cases from 1200 patients (7 %) was locally studied by contrast-enhanced CT and CTA in a referral centre: 74 malignant tumours, 14 benign lesions. Contrast-enhancement patterns and relationship of the mass with major vessels and bone were compared with histology on surgically excised samples. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) were evaluated in discriminating active from aggressive tumours. RESULTS: Sensitivity in differentiating aggressive tumours from active lesions was 89 %, specificity 84 %, PPV 90 %, NPV 82 %. The relationship between mass and major vessels/bone was fundamental for surgical strategy respectively in 40 % and in 58 % of malignant tumours. CONCLUSION: Contrast-enhanced CT and CTA are effective in differentiating aggressive masses from active lesions in soft tissue and in depicting the relationship between tumour and adjacent bones and major vessels. KEY POINTS: • Accurate delineation of vascular and bony involvement preoperatively is fundamental for a correct resection. • CT plays a critical role in differential diagnosis of soft tissue masses. • Contrast-enhanced CT and CT angiography are helpful in depicting tumoral vascular involvement. • CT is optimal for characterization of bone involvement in soft tissue malignancies.

X-ray, CT and DXA study of bone loss on medieval remains from North-West Italy.

PURPOSE: The aim of this study was to investigate whether the population differences in osteoporosis observed nowadays is a reflection of the times and modern lifestyle factors, or whether they were also present in the past. MATERIALS AND METHODS: The study was performed on the skeletal remains of medieval and post-medieval populations from a burial ground in the North-West of Italy. Some individuals had been buried inside the church (privileged subjects), others outside in the parvis (members of rural population), and others still to the north of the church. X-ray, computed tomography and dual-energy X-ray absorptiometry studies were carried out on the lumbar spines and/or femurs of 27 male and 28 female individuals to determine any associations between cortical index, bone mineral density (BMD), gender, age and social status. RESULTS: No statistically significant differences were observed in cortical index values according to gender, age or place of burial. Conversely, statistically significant differences in average BMD values were observed according to place of burial; in particular, among those buried inside the church, a lower BMD was observed compared to the parvis group (1.09 vs. 1.42, p < 0.001) and the north group (1.09 vs. 1.49, p < 0.001). CONCLUSIONS: The differences observed in the BMD values may be related to the different lifestyle of the rural population, i.e. more dietary calcium intake, more sun exposure and vigorous physical activity, compared to that of the privileged individuals.

Magnetic resonance arthrography for femoroacetabular impingement surgery: is it reliable?

BACKGROUND: Magnetic resonance arthrography (MRA) is commonly used to demonstrate injury to the labrum and hyaline cartilage in patients with femoroacetabular impingement (FAI). The purpose of this study was to assess the diagnostic correlation between MRA and findings at arthroscopic and open surgery. MATERIALS AND METHODS: MRA reports of 41 hips with symptomatic FAI were reviewed and compared with subsequent intraoperative findings (n = 21 surgical dislocations and n = 20 therapeutic hip arthroscopies). Each case was assessed for the presence of a cam deformity, a cartilage lesion of the femoral head, an os acetabuli, an injury to the labrum and injury to the acetabular cartilage. Results were collected prospectively in a cross-table and analysed retrospectively for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: The sensitivity, specificity, PPV and NPV in the presence of reported cam-type deformity or an os acetabuli were 100%. In the presence of cartilage lesions of the femoral head, the values were 46, 81, 55 and 73%, respectively. For labral tears, the values were 91, 86, 97 and 67%. In the presence of acetabular cartilage injuries, the values were 69, 88, 78 and 81%, respectively. CONCLUSIONS: MRA appears to be an efficacious imaging modality in the evaluation of labral tears, cam-type impingement lesions and os acetabuli of the hip. MRA is less efficacious in the diagnosis of cartilage abnormalities in the hip, both femoral and acetabular. Researchers should focus on further improvements in imaging techniques in order to give reliable preoperative information to the surgeon.

Accuracy of core-needle biopsy after contrast-enhanced ultrasound in soft-tissue tumours.

OBJECTIVE: Percutaneous biopsies are gaining acceptance in the diagnosis of soft-tissue tumours. Sampling in the most representative area is not easy in sarcomas of huge dimension. We hypothesised that ultrasound (US) contrast medium could identify the representative area for focus core-needle biopsy (CNB) METHODS: This is a retrospective cohort series of 115 soft-tissue masses treated from January 2007 to November 2008. Accuracy of US-guided CNB after contrast-enhanced US (CEUS) was determined by comparing the histology of the biopsy with the definitive diagnosis in 105 surgically excised samples (42 benign, 63 malignant) and with the expected outcome in the remaining ten malignant cases not surgically treated. A myxoid component was present in 21 sarcomas (34.4%). RESULTS: Of samples, 94.8% were adequate for diagnosis with 97.1% sensitivity and 92.5% specificity. Sensitivity and specificity in specific histopathological subgroupings were 100%, and in grading definition they were 100% and 96.8%. DISCUSSION: US-guided CNB is safe and effective. US contrast medium depicts tumour vascular supply and identifies the representative area(s) for sampling. Sensitivity and specificity are also high in subgrouping and grading, including myxoid types. Discussion about biopsy is part of the essential multidisciplinary strategy for these tumours.

CEUS in abdominal trauma: multi-center study.

The objective of this study was to evaluate the concordance of US and contrast-enhanced US (CEUS) with CT in the assessment of solid organ injury following blunt trauma. Patients underwent complete US examination, including free fluid search and solid organ analysis. CEUS followed, using low-mechanical index techniques and SonoVue. CT was performed within 1 h. Among 156 enrolled patients, 91 had one or more abnormalities (n = 107) at CT: 26 renal, 38 liver, 43 spleen. Sensitivity, specificity, and accuracy for renal trauma at baseline US were 36%, 98%, and 88%, respectively, after CEUS values increased to 69%, 99%, and 94%. For liver baseline US values were 68%, 97%, and 90%; after CEUS were 84%, 99%, and 96%. For spleen, results were 77%, 96%, and 91% at baseline US and 93%, 99%, and 97% after CEUS. Per patient evaluation gave the following results in terms of sensitivity, specificity and accuracy: 79%, 82%, 80% at baseline US; 94%, 89%, and 92% following CEUS. CEUS is more sensitive than US in the detection of solid organ injury, potentially reducing the need for further imaging. False negatives from CEUS are due to minor injuries, without relevant consequences for patient management and prognosis.

Imaging of long head biceps tendon. A multimodality pictorial essay.

The aim of this is article is to provide an  imaging review of normal anatomy, most common anatomical variants and pathologies of the long head of the biceps tendon (LHB) encountered during the daily practice.

Perfusion pattern and time of vascularisation with CEUS increase accuracy in differentiating between benign and malignant tumours in 216 musculoskeletal soft tissue masses.

INTRODUCTION: Musculoskeletal Soft Tissue Tumours (STT) are frequent heterogeneous lesions. Guidelines consider a mass larger than 5 cm and deep with respect to the deep fascia potentially malignant. Contrast Enhanced Ultrasound (CEUS) can detect both vascularity and tumour neoangiogenesis. We hypothesised that perfusion patterns and vascularisation time could improve the accuracy of CEUS in discriminating malignant tumours from benign lesions. MATERIALS AND METHODS: 216 STT were studied: 40% benign lesions, 60% malignant tumours, 56% in the lower limbs. Seven CEUS perfusion patterns and three types of vascularisation (arterial-venous uptake, absence of uptake) were applied. Accuracy was evaluated by comparing imaging with the histological diagnosis. Univariate and multivariate analysis, Chi-square test and t-test for independent variables were applied; significance was set at p<0.05 level, 95% computed CI. RESULTS: CEUS pattern 6 (inhomogeneous perfusion), arterial uptake and location in the lower limb were associated with high risk of malignancy. CEUS pattern has PPV 77%, rapidity of vascularisation PPV 69%; location in the limbs is the most sensitive indicator, but NPV 52%, PPV 65%. The combination of CEUS-pattern and vascularisation has 74% PPV, 60% NPV, 70% sensitivity. No correlation with size and location in relation to the deep fascia was found. CONCLUSION: US with CEUS qualitative analysis could be an accurate technique to identify potentially malignant STT, for which second line imaging and biopsy are indicated in Referral Centers. Intense inhomogeneous enhancement with avascular areas and rapid vascularisation time could be useful in discriminating benign from malignant SST, overall when the lower limbs are involved.

Postmeniscectomy osteonecrosis.

In the last few years, postmeniscectomy osteonecrosis has been reported, especially in elderly patients, with low incidence, unclear physiopathology, and without long periods of follow-up. We report a case diagnosed and followed-up for a 3-year period using magnetic resonance imaging. In the initial phase, a large area of intramedullary edema was evident; after 3 months, the edema had decreased (it was no longer evident at 1 year examination) and a clearly defined area of osteonecrosis was evident with very high signal intensity on high-contrast sequences. After 3 years, the lesion showed a degenerative cyst appearance with an osteosclerotic rim and completely disrupted cartilage.

Osteoid osteoma: our experience using radio-frequency (RF) treatment.

PURPOSE: To present the results of two years experience with a minimally invasive radio-frequency technique designed by our team in the treatment of osteoid osteoma. MATERIALS AND METHODS: A total of 21 osteoid osteoma patients (15 males, 6 females, age range 13 to 34 yrs) were treated between January 2001 and April 2003. Localizations of the osteoid osteoma were the pelvis (n = 1), the femur (n = 12), the tibia (n = 3), the foot (n = 3), and the humerus (n = 2). All patients underwent an X-ray examination, a CT scan and a bone Scintiscan. In the initial phase, a K-wire just slightly larger than the 17G needle electrode is positioned manually at the zenith of the target area under CT guidance and using an orthopaedic drill it is inserted at the centre of the nidus. A tailor-made metal sheath is inserted on the K-wire to create a ''tunnel'' through which the needle electrode can substitute the K-wire; at the same time, the electrode needle is positioned inside the lesion. The temperature of the exposed tip of the needle is 90 degrees C and duration of hyperthermia is 6 minutes on average. Once the procedure has been completed, a scan os performed to measure the density of the treated site and this measurement is then used as an evolution index for the evaluation of the healing process during follow-up. RESULTS: No serious complications were observed at follow-up. General anaesthesia was only required in the case with hip involvement; peripheral anaesthesia was used in all the other cases. Complete resolution of the pain was reported in all cases after a maximum of three weeks. DISCUSSION AND CONCLUSIONS: After two years experience, we believe percutaneous RF treatment of osteoid osteoma to be the first choice technique when compared to traditional surgery due to the fact that it is almost non-invasive, quick, repeatable if need be and offers a high reduction in costs. Moreover early weight bearing is the norm and the patient is dismissed after only one day of hospitalization. The clinical results indicate a 100% success rate with complete remission of symptoms and no relapses having been reported at the time of writing for those patients who have arrived at the two year follow up (4 out of 21).

Contrast enhanced gray-scale sonography in assessment of joint vascularity in rheumatoid arthritis: results from the IACUS study group.

The purpose of this study way to assess the value of contrast enhanced gray-scale ultrasound (CEUS) in detection of vascularity in joints of patients with rheumatoid arthritis (RA) in a multicenter study of the International Arthritis Contrast Ultrasound (IACUS) study group. We assessed 113 joints in 113 patients (44 men, 69 women; mean age 51+/-14 years) with clinical diagnosis of RA. Gray-scale ultrasound (US), power Doppler US (PDUS) and CEUS, using a low mechanical index US technique, was performed. CEUS was done by bolus administration of the contrast agent SonoVue (Bracco, Milan, Italy) with a dosage of 4.8-ml SonoVue flushed with 10 ml saline. Detection of joint vascularity was performed for differentiation of active synovitis from inactive intra-articular thickening (synovitis/effusion). With the use of US and PDUS, active synovitis could be differentiated from inactive intra-articular thickening in 68/113 joints (60.1%), whereas CEUS enabled differentiation in 110/113 (97.3%) joints (p<0.0001). Thickness measurement of active synovitis was significantly improved after contrast administration (p=0.008). In conclusion, CEUS improves the differentiation of active synovitis from inactive intra-articular thickening. Since CEUS has shown an ability to improve assessment of vascularized synovial proliferation in RA affected joints, this technique may have further potential in monitoring therapy.

A preliminary experience in the study of soft tissue superficial masses. Color-Doppler US and wash-in and wash-out curves with contrast media compared to histological result.

PURPOSE: A morphological analysis of wash-in and wash-out curves was carried out to assess their significance in the evaluation of superficial masses with US after the introduction of contrast medium, and to compare the findings with the histological analysis. MATERIALS AND METHODS: From April to December 2000 we studied 70 patients with palpable masses in different body sites. Each patient underwent US examination at baseline and after the introduction of Levovist contrast medium (Schering, Berlin, Germany), performed with an AU5 Harmonic device (Esaote Biomedica, Genoa, Italy), using linear probes with frequencies ranging from 7.5 to 13 MHz and software assessing wash-in and wash-out curves. All the patients underwent surgical excision of the mass. Histological confirmation of the nature of the mass was therefore available for all cases. RESULTS: Out of 70 examined patients, 43 had benign and 27 had malignant lesions. In cases of dubious interpretation of ultrasound and MR imaging, color Doppler US with contrast medium and the subsequent analysis of wash-in and wash-out curves exhibited a particular curve pattern indicating the nature of the lesion. DISCUSSION AND CONCLUSIONS: Based on the preliminary data gathered, we believe that the analysis of wash-in and wash-out curves can be useful and reliable in diagnosing an expansile soft tissue lesions. Because our study is still in its early stages and is based on a small number of cases, no conclusions can be drawn as yet but just an observation and description of data obtained.

MR Arthrography: a proposal for solution optimization with lidocaine. An in vitro experience.

PURPOSE: Pain on capsule distension in painful joints may affect feasibility of the MR Arthrography. We tried to overcome this limitation by adding a local anesthetic (lidocaine) to the paramagnetic contrast agent solution. We aimed at: a) investigating which contrast agent dilution provides the best signal-to-noise ratio in the SE T1 sequences; b) evaluating the effects of lidocaine on the signal intensity and on the viscosity of the solutions; assessing the viscosity of solutions containing iodinated contrast agent. MATERIALS AND METHODS: The paramagnetic contrast agent was diluted with saline and lidocaine at various concentrations. Signal intensity was measured with a 1.5 Tesla superconductive MR unit with a dedicated head coil; we used T1-weighted spin-echo sequence. The viscosity coefficient of the solutions was analyzed and compared with that of solutions containing iodinated contrast agents (but not lidocaine). RESULTS: Signal intensity is also unaffected by variations in the concentration of lidocaine, which does not interfere with the biphasic behavior of Gadolinium. Viscosity is scarcely affected by changes in lidocaine concentration when the paramagnetic contrast agent concentration is not changed. CONCLUSIONS: The optimal signal-to-noise ratio in T1-weighted sequences is provided by 0.4%, contrast agent dilution but contrast agent-saline solutions, with(out) lidocaine, cannot be considered steady and signal intensity values change over time. The addition of lidocaine does not significantly influence the signal-to-noise ratio and the viscosity of the solutions. The low viscosity of the paramagnetic contrast agent appears to favor quicker spread of the solution, even in tiny defects; thanks to its anesthetic effect, lidocaine could facilitates execution of the examination in painful joints without affecting the diagnostic result.