Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2023-overview, and primary local imaging: how and where?

OBJECTIVES: Early, accurate diagnosis is crucial for the prognosis of patients with soft tissue sarcomas. To this end, standardization of imaging algorithms, technical requirements, and reporting is therefore a prerequisite. Since the first European Society of Musculoskeletal Radiology (ESSR) consensus in 2015, technical achievements, further insights into specific entities, and the revised WHO-classification (2020) and AJCC staging system (2017) made an update necessary. The guidelines are intended to support radiologists in their decision-making and contribute to interdisciplinary tumor board discussions. MATERIALS AND METHODS: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements were scored online by level of agreement (0 to 10) during two iterative rounds. Either "group consensus," "group agreement," or "lack of agreement" was achieved. RESULTS: Eight sections were defined that finally contained 145 statements with comments. Overall, group consensus was reached in 95.9%, and group agreement in 4.1%. This communication contains the first part consisting of the imaging algorithm for suspected soft tissue tumors, methods for local imaging, and the role of tumor centers. CONCLUSION: Ultrasound represents the initial triage imaging modality for accessible and small tumors. MRI is the modality of choice for the characterization and local staging of most soft tissue tumors. CT is indicated in special situations. In suspicious or likely malignant tumors, a specialist tumor center should be contacted for referral or teleradiologic second opinion. This should be done before performing a biopsy, without exception. CLINICAL RELEVANCE: The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability both in individual patients and in future studies on individualized strategies. KEY POINTS: • Ultrasound remains the best initial triage imaging modality for accessible and small suspected soft tissue tumors. • MRI is the modality of choice for the characterization and local staging of soft tissue tumors in most cases; CT is indicated in special situations. Suspicious or likely malignant tumors should undergo biopsy. • In patients with large, indeterminate or suspicious tumors, a tumor reference center should be contacted for referral or teleradiologic second opinion; this must be done before a biopsy.

Ankle and Foot: Focus on Inflammatory Disease.

The ankle and foot have numerous bones and complex joints that can be affected by several types of inflammatory arthritis with different patterns and various radiologic signs, depending on the phase of the disease. Involvement of these joints is most frequently seen in peripheral spondyloarthritis and rheumatoid arthritis in adults and juvenile idiopathic arthritis in children. Although radiographs are a mainstay in the diagnostic process, ultrasonography and especially magnetic resonance imaging allow early diagnosis and are crucial diagnostic tools. Some diseases have typical features based on target populations (e.g., adults versus children, men versus women), but others may have overlapping imaging characteristics. We highlight key diagnostic features and describe appropriate investigations to guide clinicians toward the correct diagnosis and provide support during disease monitoring.

Current Role of Conventional Radiography of Sacroiliac Joints in Adults and Juveniles with Suspected Axial Spondyloarthritis: Opinion from the ESSR Arthritis and Pediatric Subcommittees.

This opinion article by the European Society of Musculoskeletal Radiology Arthritis and Pediatric Subcommittees discusses the current use of conventional radiography (CR) of the sacroiliac joints in adults and juveniles with suspected axial spondyloarthritis (axSpA). The strengths and limitations of CR compared with magnetic resonance imaging (MRI) and computed tomography (CT) are presented.Based on the current literature and expert opinions, the subcommittees recognize the superior sensitivity of MRI to detect early sacroiliitis. In adults, supplementary pelvic radiography, low-dose CT, or synthetic CT may be needed to evaluate differential diagnoses. CR remains the method of choice to detect structural changes in patients with suspected late-stage axSpA or established disease and in patients with suspected concomitant hip or pubic symphysis involvement. In children, MRI is the imaging modality of choice because it can detect active as well as structural changes and is radiation free.

Phosphaturic mesenchymal tumors: radiological aspects and suggested imaging pathway.

Phosphaturic mesenchymal tumors (PMTs) are rare mesenchymal neoplasms of soft tissue or bone origin that can give rise to a challenge in diagnostic imaging. These tumors are frequently associated with tumor-induced osteomalacia, also called oncogenic osteomalacia, which is a rare paraneoplastic syndrome characterized by ectopic secretion of fibroblast growth factor 23, a hormone that regulates serum phosphate level. PMTs show polymorphic features on both radiological findings and histological examination, causing problems in diagnosis owing to their similarity with other mesenchymal tumors. Thus, this paper aims to describe radiological aspects of PMTs and suggest an imaging pathway for accurate diagnosis throughout the evidence from the literature review.

Non-neoplastic Soft Tissue Tumors and Tumor-like Lesions.

Clinicians are commonly faced with patients presenting with a solitary palpable soft tissue mass. Most soft tissue lesions are benign, and not every mass is due to a neoplastic process. Many pathologies can mimic a malignant tumor. Despite appropriate clinicoradiologic assessment, these lesions can be mistaken for a soft tissue sarcoma and can lead to multiple investigations or an intervention, inconveniencing patients and leading to an increased health care cost. With the relevant clinical history, clinical examination, and specific imaging characteristics, the diagnosis can be narrowed. We present a pictorial review of soft tissue sarcoma mimics with guidance on appropriate differential diagnoses.

Concurrent Joint Hypermobility Syndrome and Spondyloarthropathy: A New Spondyloarthropathy Subgroup With a Less Severe Disease Phenotype?

BACKGROUND: The coexistence of joint hypermobility syndrome (JHS) and spondyloarthropathy (SpA) presents a challenging clinical conundrum due to the contradictory clinical signs that may be present. Classic features such as restricted spinal movement or early morning back stiffness may not be present. Timely diagnosis and appropriate management of these patients are difficult as they tend to have lower scores on validated objective measures. METHODS: We performed a medical records review study to identify patients with both JHS and SpA who had presented to the Leicester Spondyloarthropathy clinic. Patients were diagnosed with axial SpA if they met the Assessment of SpondyloArthritis international Society classification criteria. Their imaging was reviewed by a consultant musculoskeletal radiologist. RESULTS: Four cases were identified from the patient database (female; average age, 37.5 years). All patients presented with lower back pain or sacroiliac joint pain but preserved spinal movement with a negative Schober's test. Two had a history of symptoms for more than 10 years. All had a Beighton score of greater than 6. Three of the patients were HLA positive, and 3 had a positive family history. All patients thus far have had their symptoms adequately controlled on nonsteroidal anti-inflammatory drugs and physiotherapy. CONCLUSIONS: The coexistence of JHS and SpA is rare but important to recognize. These patients are difficult to diagnose as they may present late because of preserved spinal movements. It is unclear whether the preserved flexibility masks the true extent of disease or whether clinically they represent a less severe disease phenotype.

Standard and Advanced Imaging of Hip Osteoarthritis. What the Radiologist Should Know.

Osteoarthritis (OA) of the hip is caused by degeneration of articular cartilage and the underlying bone and can be divided into two types: primary (associated with advancing age) and secondary (subsequent to fractures, avascular necrosis, infection, developmental dysplasia, and femoroacetabular impingement). Radiography remains the first-line imaging modality for diagnosing and monitoring OA, due to its accessibility, low cost, and ease of interpretation. Kellgren-Lawrence and Tönnis classification systems are radiographic OA grading systems used primarily in research, and they reflect the degree of joint space narrowing, sclerosis, cysts, deformity of the femoral head and acetabulum, and osteophytes. Unenhanced computed tomography (CT) provides detailed visualization of the hip joint segments that may be difficult to appreciate on radiographs, such as the inferoposterior and posterolateral hip joint. CT arthrography, magnetic resonance imaging (MRI), and magnetic resonance arthrography with two-dimensional reconstructions can delineate labral abnormalities, cartilage lesions, and other intra-articular hip pathology. T2 and T2* mapping, delayed gadolinium-enhanced MRI of cartilage, T1rho, ultra-short echo time, and zero echo time are investigative MR techniques with promising evaluation of hip OA.

Anterior Chest Wall in Axial Spondyloarthritis: Imaging, Interpretation, and Differential Diagnosis.

Anterior chest wall (ACW) inflammation is not an uncommon finding in patients with axial spondyloarthritis (ax-SpA) and reportedly occurs in 26% of these patients. Radiologists may only be familiar with spinal and peripheral joint imaging, possibly due to the inherent challenges of ACW imaging on some cross-sectional imaging modalities. Knowledge of relevant joint anatomy and the location of sites of inflammation allows the interpreting radiologist to better plan appropriate imaging tests and imaging planes. Accurate assessment of disease burden, sometimes in the absence of clinical findings, may alert the treating rheumatologist, allowing a better estimation of disease burden, increased accuracy of potential imaging scoring systems, and optimize assessment and response to treatment. This article reviews salient anatomy and various imaging modalities to optimize diagnosis, important differential diagnoses, and the interpretation of ACW imaging findings in ax-SpA.

Recommendations of the ESSR Arthritis Subcommittee on Ultrasonography in Inflammatory Joint Disease.

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee on the use of ultrasonography (US) in rheumatic disease, focused on the examination of joints in the adult population. The recommended examination technique and protocols used in a radiologic work-up are discussed. The main US features that can lead to a final diagnosis in the most common rheumatic diseases are addressed. The differential diagnosis that should be considered at image interpretation is presented. The role of US in interventional procedures and clinically important recent developments is also discussed.

Percutaneous Ultrasound-Guided TOPAZ Radiofrequency Coblation: A Novel Coaxial Technique for the Treatment of Recalcitrant Plantar Fasciitis-Our Experience.

Various therapeutic options are available for treatment of recalcitrant plantar fasciitis. Studies using TOPAZ coblation (ArthroCare, Sunnyvale, CA) have had good early results. The current coblation technique involves a surgical incision or breach of the highly specialized plantar fat pad, which can be associated with risks. We describe a novel technique of ultrasound-guided percutaneous coblation with a lateral heel approach. Advantages include precise targeting of the plantar fascia by direct dynamic visualization of the coblation tip, a true percutaneous approach with a needle skin puncture (<5 mm), and preservation of the plantar fat pad by using a lateral heel approach.

Recommendations of the ESSR Arthritis Subcommittee for the Use of Magnetic Resonance Imaging in Musculoskeletal Rheumatic Diseases.

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee regarding the standards of the use of MRI in the diagnosis of musculoskeletal rheumatic diseases. The recommendations discuss (1) the role of MRI in current classification criteria of musculoskeletal rheumatic diseases (including early diagnosis of inflammation, disease follow-up, and identification of disease complications); (2) the impact of MRI on the diagnosis of axial and peripheral spondyloarthritis, rheumatoid arthritis, and juvenile spondyloarthritis; (3) MRI protocols for the axial and peripheral joints; (4) MRI interpretation and reporting for axial and peripheral joints; and finally, (5) methods for assessing MR images including quantitative, semiquantitative, and dynamic contrast-enhanced MRI studies.

The Human Botfly "Bubbling Sign": Ultrasound Features of Cutaneous Furuncular Myiasis.

Dermatobia hominis , the human botfly, is native to South and Central America with cases of infestation seen in travelers to these areas. Myiasis is the cutaneous manifestation of larvae between two periods of molting (instar) and presents as a firm furuncular mass with a central pore that can be easily clinically overlooked. Ultrasound is useful in the diagnostic workup and has specific features and techniques to demonstrate live larva. We present a patient who acquired cutaneous furuncular myiasis caused by D. hominis , the human botfly, during her jungle trek in the Amazon forests in South America. Over 5 weeks, she developed a firm furuncular lesion with a central pore. Ultrasound revealed a hypoechoic mass with a hyperechoic oblong-shaped core that showed a fluid circulation, confirming the presence of a viable larva. Surgery was performed and a second-instar D. hominis larva was confirmed. We discuss the key ultrasound findings and management of cutaneous furuncular myiasis with the aim of raising awareness of this condition, adding to the growing body of literature likely associated with the re-opening of global travel routes.

Image quality in whole-body MRI using the MY-RADS protocol in a prospective multi-centre multiple myeloma study.

BACKGROUND: The Myeloma Response Assessment and Diagnosis System (MY-RADS) guidelines establish a standardised acquisition and analysis pipeline for whole-body MRI (WB-MRI) in patients with myeloma. This is the first study to assess image quality in a multi-centre prospective trial using MY-RADS. METHODS: The cohort consisted of 121 examinations acquired across ten sites with a range of prior WB-MRI experience, three scanner manufacturers and two field strengths. Image quality was evaluated qualitatively by a radiologist and quantitatively using a semi-automated pipeline to quantify common artefacts and image quality issues. The intra- and inter-rater repeatability of qualitative and quantitative scoring was also assessed. RESULTS: Qualitative radiological scoring found that the image quality was generally good, with 94% of examinations rated as good or excellent and only one examination rated as non-diagnostic. There was a significant correlation between radiological and quantitative scoring for most measures, and intra- and inter-rater repeatability were generally good. When the quality of an overall examination was low, this was often due to low quality diffusion-weighted imaging (DWI), where signal to noise ratio (SNR), anterior thoracic signal loss and brain geometric distortion were found as significant predictors of examination quality. CONCLUSIONS: It is possible to successfully deliver a multi-centre WB-MRI study using the MY-RADS protocol involving scanners with a range of manufacturers, models and field strengths. Quantitative measures of image quality were developed and shown to be significantly correlated with radiological assessment. The SNR of DW images was identified as a significant factor affecting overall examination quality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03188172 , Registered on 15 June 2017. CRITICAL RELEVANCE STATEMENT: Good overall image quality, assessed both qualitatively and quantitatively, can be achieved in a multi-centre whole-body MRI study using the MY-RADS guidelines. KEY POINTS: • A prospective multi-centre WB-MRI study using MY-RADS can be successfully delivered. • Quantitative image quality metrics were developed and correlated with radiological assessment. • SNR in DWI was identified as a significant predictor of quality, allowing for rapid quality adjustment.

Implementation of Whole-Body MRI (MY-RADS) within the OPTIMUM/MUKnine multi-centre clinical trial for patients with myeloma.

BACKGROUND: Whole-body (WB) MRI, which includes diffusion-weighted imaging (DWI) and T1-w Dixon, permits sensitive detection of marrow disease in addition to qualitative and quantitative measurements of disease and response to treatment of bone marrow. We report on the first study to embed standardised WB-MRI within a prospective, multi-centre myeloma clinical trial (IMAGIMM trial, sub-study of OPTIMUM/MUKnine) to explore the use of WB-MRI to detect minimal residual disease after treatment. METHODS: The standardised MY-RADS WB-MRI protocol was set up on a local 1.5 T scanner. An imaging manual describing the MR protocol, quality assurance/control procedures and data transfer was produced and provided to sites. For non-identical scanners (different vendor or magnet strength), site visits from our physics team were organised to support protocol optimisation. The site qualification process included review of phantom and volunteer data acquired at each site and a teleconference to brief the multidisciplinary team. Image quality of initial patients at each site was assessed. RESULTS: WB-MRI was successfully set up at 12 UK sites involving 3 vendor systems and two field strengths. Four main protocols (1.5 T Siemens, 3 T Siemens, 1.5 T Philips and 3 T GE scanners) were generated. Scanner limitations (hardware and software) and scanning time constraint required protocol modifications for 4 sites. Nevertheless, shared methodology and imaging protocols enabled other centres to obtain images suitable for qualitative and quantitative analysis. CONCLUSIONS: Standardised WB-MRI protocols can be implemented and supported in prospective multi-centre clinical trials. Trial registration NCT03188172 clinicaltrials.gov; registration date 15th June 2017 https://clinicaltrials.gov/ct2/show/study/NCT03188172.

Imaging update in spondyloarthropathy.

Although our understanding of axial spondyloarthropathy (axSpA) has increased recently, there has not been a concurrent improvement in patient diagnosis with delays contributing to patient morbidity. Imaging findings of axSpA can be subtle and may be dismissed often due to lack of understanding by reporters and importantly clinicians who do not suspect the disease. Recognition of the importance of imaging has led to the inclusion of MRI as part of the diagnostic criteria for axSpA. With this in mind, a number of advancements have been made in an attempt to increase our diagnostic accuracy on imaging. This article will give an overview of these techniques as well as a recap of the imaging features of axSpA.

Is There a Correlation Between Patient-Reported Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) Score and MRI Findings in Axial Spondyloarthropathy in Routine Clinical Practice?

Background The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is the patient-reported outcome (PRO) that is routinely used in clinical practice to monitor and measure disease activity in axial spondyloarthropathy (axSpA). BASDAI scores greater than four are thought to indicate active disease and require better control. Magnetic resonance imaging (MRI) is the most objective measure of disease activity in axSpA with its ability to pick up active inflammation both in the spine and sacroiliac joints. Previous studies have shown conflicting correlations between BASDAI and MRI, and therefore, there is the question of whether BASDAI is the best tool to monitor disease activity when it is subjective and potentially influenced by other patient factors. We, therefore, conducted a retrospective study to investigate the correlation between BASDAI and MRI in axSpA patients. Methodology Data were collected by retrospective analysis of axSpA patients attending University of Leicester (UHL) axSpA services. BASDAI scores were done within a year and closest to the time of MRI spine + sacroiliac joints were collected. The results prior to the initiation of biologic therapy were used. Data of one hundred and forty-nine patients were collected on their MRI results and BASDAI scores. Data were analysed using Statistical Package for the Social Sciences (SPSS) software and Pearson's chi-squared applied to assess the correlation between BASDAI and MRI findings. Results Out of one hundred and forty-nine patients, 61.7% had active sacroiliitis on their MRI, 57.7% had chronic sacroiliitis, 53% had active spinal inflammation, and 17.4% had other MRI findings of active disease. There was a significant correlation between active sacroiliitis and BASDAI (p=0.014), but similar results were not found with other radiological features. A significant correlation was also found with males having higher BASDAI scores compared to females (p=0.027). Conclusion This study demonstrates a statistically significant correlation between BASDAI and active sacroiliitis with those having higher scores more likely to have active disease on their MRI.

Imaging update on soft tissue sarcoma.

Soft tissue sarcomas (STS) are rare tumours presenting as soft tissue lumps. Ultrasound is often the primary modality for the initial assessment, with MRI the mainstay for lesion characterisation. PET/CT along with other emerging MRI sequences are used in certain situations as an adjunct and problem solving tool in STS staging and assessment of disease recurrence. Recent advances include the promise of whole body MRI, hybrid PET/MRI, diffusion weighted imaging, dynamic contrast enhanced MRI and advances in artificial intelligence. This article discusses current concepts in extremity STS imaging and highlights recent advances.

Classification Terminology and Definitions in Reporting of MRI in Axial Spondyloarthritis.

Spondyloarthritis (SpA) is a group of chronic inflammatory conditions which severely impact quality of life. Several criteria have been developed in the past to aid the diagnosis of SpA based on symptoms and radiographic changes during the course of the disease. However, it takes several years before structural changes manifest on conventional radiographs, leading to a diagnostic delay of 6 to 10 years. The use of MRI and its incorporation into the Assessment of Spondyloarthritis (ASAS) criteria, has radically changed the diagnosis of SpA in the last decade by allowing visualisation of both active and chronic inflammatory changes and enabling clinicians to recognise SpA during it's early stage and initiate treatment. An understanding of the various terminology used in the divisions of disease presentations and their relevant imaging findings are key, along with the use of clear definitions of structural and inflammatory changes on MRI, in ensuring accurate diagnosis and classification of SpA.