Unusual soft tissue metastases in a patient with chondrosarcoma: a case report.

Chondrosarcoma (CS) is the second most frequent primary malignant bone tumour, characterized by production of non-osteoid cartilage matrix. Up to more than 30% of patients with CS present distant metastases, and the lungs represent the preferred site. Hence, CS soft tissue metastases and superficial cutaneous lesions are extremely rare. We report the case of a female who developed unusual multiple soft tissue CS metastases. This patient underwent left hindquarter amputation for recurrent grade 3 chondrosarcoma of the femoral neck with extension to the pelvis approximately 4 years after internal fixation with an intramedullary nail for pathological fracture of left proximal femur and subsequent total proximal femoral endoprosthetic replacement for grade 1-2 chondrosarcoma. In the following years, she underwent metastasectomy for several grade 2 pulmonary metastatic chondrosarcomas. More than 14 years after the amputation, she presented with multiple unusual superficial cutaneous lesions, and a whole-body magnetic resonance imaging demonstrated multiple soft tissue foci of metastatic disease. The histology of multiple soft tissue lesions excised confirmed metastatic chondrosarcoma. Then, she underwent marginal excision of further multifocal soft tissue metastatic high-grade chondrosarcoma. Unlike the poor survival from the onset of these metastases in the other cases reported in the literature, our patient is still alive 2 years after the first multiple soft tissue excision of metastatic chondrosarcoma, and approximately 20 years after the diagnosis of chondrosarcoma. Soft tissue CS metastases are a rare entity with few cases described in literature. This study aims to make the reader aware of this lesser-known CS manifestation.

An unusual case of nodular fasciitis presenting as an intra-tendinous mass.

Nodular fasciitis is a benign soft tissue pseudotumour typically occurring in the upper extremities, head and neck, thigh and trunk. It is most commonly seen in subcutaneous locations but also can be present in intramuscular and intermuscular (fascial) locations. Its occurrence in the hand is rare, and while it can occur in close proximity to tendons, its presentation as an intra-tendinous mass has not been previously described. We present a unique and rare case of nodular fasciitis arising within the flexor digitorum profundus (FDP) tendon of the hand in a 16-year-old female. The patient presented with a painful swelling in the volar aspect of the base of her left middle finger, with progressive flexion deformity of the finger. Ultrasound and magnetic resonance imaging revealed a mass within the FDP tendon of the middle finger. An ultrasound-guided biopsy revealed a diagnosis of nodular fasciitis. Given the self-limiting nature of the condition, she was managed conservatively with close clinical and imaging follow-up. This case highlights the importance of considering nodular fasciitis in the differential diagnosis of an intra-tendinous lesion in the hand, even though it is a rare occurrence in this location. The clinical presentation, diagnostic workup, and management of this unique case are discussed, emphasising the potential for its misdiagnosis as a malignancy which can have important implications in management.

An Unusual Case of Calcific Periarthritis Causing Carpal Tunnel Syndrome and Its Management with Ultrasound-Guided Barbotage.

Hydroxyapatite crystal deposition disease (HADD) is a common disorder resulting from the deposition of calcium hydroxyapatite crystals in various soft tissues, typically in periarticular distribution, including tendons, tendon sheaths, joint capsules, ligaments, bursae, periarticular soft tissues, and occasionally within the joints. The more commonly known subtypes of HADD are calcific tendinopathy and calcific periarthritis. Carpal tunnel syndrome (CTS) can be rarely caused by calcific deposits within the carpal tunnel in the setting of HADD-related calcific periarthritis. Imaging, particularly ultrasound and radiographs, is crucial in distinguishing this entity from the conventional form of CTS that tends to be idiopathic. We describe a rare presentation of CTS secondary to calcific periarthritis in a 45-year-old patient, with imaging demonstrating mass-like calcification within the carpal tunnel, with typical features of those seen with HADD. The patient was treated with ultrasound-guided barbotage, with significant clinical improvement. The case highlights a lesser-known cause of CTS as well as a presentation of HADD, and the role of ultrasound-guided barbotage, a minimally invasive procedure, as a viable first-line management option as an alternative to surgery.

An unusual cystic presentation of pelvic skeletal Ewing sarcoma: a case series.

Ewing sarcoma (ES) is the second most common primary malignant bone tumour in children and adolescents. About 14.5% of primary malignancies develop in pelvic bones, where they typically have worse prognoses than extremity or acral sarcomas. It usually presents with aggressive features on radiology scans, but may also present with different radiological characteristics. In this series, we describe rare appearances of pelvic skeletal Ewing sarcoma, with large extraosseous cystic component on imaging, defined by the presence of fluid-filled spaces in the extraosseous tumour lesion, which distinguishes it from the solid nature of conventional ES. We report 3 cases of cystic presentation of ES, with imaging features supporting diagnosis of a primary malignant bone tumour arising from the superior pubic ramus with associated massive intrapelvic solid and cystic mass. CT-guided biopsy provided diagnosis of ES, with large intrapelvic soft tissue and cystic component. These patients underwent neo-adjuvant chemotherapy and proton beam therapy with significant reduction in size of the solid components, while the cystic components remained relatively unchanged. Two patients underwent surgical resection of the tumour (navigated P3 internal hemipelvectomy and hemipelvis P2/P3 resection, respectively), and one patient died while on treatment. In both who underwent surgery, histology showed ES with margins clear and more than 99% of treatment-induced necrosis. To the authors' knowledge, this unusual presentation of pelvic ES is described for the first time in the literature as a case series, with particular reference to atypical extraosseous cystic changes, along with the clinical and radiological characteristics, and their treatment.

A novel technique for performing aspiration biopsies - A technical report.

An aspiration biopsy is a commonly performed procedure for diagnostic sampling, particularly for sampling of cystic soft tissue lesions and bone marrow. The method is also useful for diagnostic sampling of bone lesions, particularly cystic and lytic osseous lesions where traditional methods of core biopsy may yield little to no material. Performing a successful aspiration biopsy involves aspiration of the lesion's contents and curettage of the walls. This requires maintaining a constant negative pressure on the syringe, which can be challenging with bone biopsies, as it requires one hand to maintain significant pressure on the plunger while the other hand manipulates the needle within the lesion. We describe a novel technique for performing aspiration biopsies of these lesions which allows maintenance of constant negative pressure on the syringe and frees up both the proceduralist's hands for better control of the needle.

An unusual case of metastatic melanoma in subcutaneous tissue presenting as a solitary cystic mass with fluid levels.

Malignant melanoma is a common and often aggressive neoplasm of the skin arising from melanocytes. Metastatic melanoma is known for its diverse clinical manifestations, and can present with atypical features prior to diagnosis of the primary lesion, which can pose a diagnostic challenge. We report a rare case of metastatic melanoma in a 67 year-old male who presented with a painless, enlarging mass in the right axilla over a 4 week period. Ultrasound and magnetic resonance imaging (MRI) scans revealed a well-defined solitary, cystic appearing lesion in the right axilla with a distinct fluid-fluid level. An ultrasound guided biopsy of the lesion diagnosed a metastatic melanoma. While haemorrhagic distant metastases are a well-recognised complication of malignant melanoma, particularly in the brain and lung, soft tissue metastases presenting with fluid-fluid levels is not well described in the literature. The case highlights the importance of considering the differential of melanoma metastasis when encountered with such a lesion and importance of ultrasound guided biopsy for histopathological confirmation, as the imaging features can mimic that of a haemorrhagic soft tissue sarcoma, the management of which differs substantially from that of melanoma.

An unusual case of primary tuberculosis of the patella and patellar tendon masquerading as gout.

Tuberculosis (TB), an infection caused by Mycobacterium tuberculosis, accounts for significant morbidity and mortality worldwide. While primary TB predominantly involves the respiratory system, approximately 10-19% patients have musculoskeletal involvement. We present a case of a 54-year-old year gentleman with insidious onset of anterior knee pain. Imaging demonstrated a soft tissue lesion involving the patellar tendon and eroding the inferior pole of the patella. The imaging features, particularly ultrasound, resembled those that are typically seen with gout. Ultrasound guided biopsy revealed this to be TB of the patella. The patient was successfully treated with antitubercular therapy. Musculoskeletal TB, while usually not a primary form of TB, is an important consideration particularly in patients with risk factors for the disease. Its imaging features can mimic other forms of arthropathy such as gout. Moreover, while the knee is a relatively common site for TB infection, isolated involvement of the patella and patellar tendon is extremely rare. The case highlights the possibility of rare musculoskeletal manifestation of TB as a well as a potential imaging pitfall of TB infection mimicking gout, which is an important consideration in clinical practice.

The clinical significance of indeterminate pulmonary nodules in patients with primary bone sarcoma: a systematic review.

OBJECTIVE: To report the incidence of indeterminate pulmonary nodules (IPN) and the rate of progression of IPNs to metastasis in patients with primary bone cancers. We also aimed to evaluate clinical or radiological parameters that may identify IPNs more likely to progress to metastatic disease and their effect on overall or event-free survival in patients with primary bone sarcoma. METHODS: A systematic search of the electronic databases Medline, Embase, and Cochrane Library was undertaken for eligible articles on IPNs in patients with primary bone sarcomas, published in the English language from inception of the databases to 2023. The Newcastle-Ottawa Quality Assessment Form for Cohort Studies was utilized to evaluate risk of bias in included studies. RESULTS: Six studies, involving 1667 patients, were included in this systematic review. Pooled quantitative analysis found the rate of incidence of IPN to be 18.1% (302 out of 1667) and the rate of progression to metastasis to be 45.0% (136 out of 302). Nodule size (more than 5 mm diameter), number (more than or equal to 4), distribution (bilaterally distributed), incomplete calcification, and lobulated margins were associated with an increased likelihood of IPNs progressing to metastasis, however, their impact on overall or event-free survival remains unclear. CONCLUSION: The risk of IPNs progressing to metastasis in patients with primary bone sarcoma is non-negligible. Large IPNs have a high risk to be an actual metastasis. We suggest that IPNs in these patients be followed up for a minimum of 2 years with CT imaging at 3, 6, and 12 month intervals, particularly for nodules measuring >5 mm in average diameter. ADVANCES IN KNOWLEDGE: This is the first systematic review on IPNs in patients with primary bone sarcomas only and proposes viable management strategies for such patients.

Exploring the potential of ChatGPT in the peer review process: An observational study.

BACKGROUND: Peer review is the established method for evaluating the quality and validity of research manuscripts in scholarly publishing. However, scientific peer review faces challenges as the volume of submitted research has steadily increased in recent years. Time constraints and peer review quality assurance can place burdens on reviewers, potentially discouraging their participation. Some artificial intelligence (AI) tools might assist in relieving these pressures. This study explores the efficiency and effectiveness of one of the artificial intelligence (AI) chatbots, ChatGPT (Generative Pre-trained Transformer), in the peer review process. METHODS: Twenty-one peer-reviewed research articles were anonymised to ensure unbiased evaluation. Each article was reviewed by two humans and by versions 3.5 and 4.0 of ChatGPT. The AI was instructed to provide three positive and three negative comments on the articles and recommend whether they should be accepted or rejected. The human and AI results were compared using a 5-point Likert scale to determine the level of agreement. The correlation between ChatGPT responses and the acceptance or rejection of the papers was also examined. RESULTS: Subjective review similarity between human reviewers and ChatGPT showed a mean score of 3.6/5 for ChatGPT 3.5 and 3.76/5 for ChatGPT 4.0. The correlation between human and AI review scores was statistically significant for ChatGPT 3.5, but not for ChatGPT 4.0. CONCLUSION: ChatGPT can complement human scientific peer review, enhancing efficiency and promptness in the editorial process. However, a fully automated AI review process is currently not advisable, and ChatGPT's role should be regarded as highly constrained for the present and near future.

Could ChatGPT Pass the UK Radiology Fellowship Examinations?

RATIONALE AND OBJECTIVES: Chat Generative Pre-trained Transformer (ChatGPT) is an artificial intelligence (AI) tool which utilises machine learning to generate original text resembling human language. AI models have recently demonstrated remarkable ability at analysing and solving problems, including passing professional examinations. We investigate the performance of ChatGPT on some of the UK radiology fellowship equivalent examination questions. METHODS: ChatGPT was asked to answer questions from question banks resembling the Fellowship of the Royal College of Radiologists (FRCR) examination. The entire physics part 1 question bank (203 5-part true/false questions) was answered by the GPT-4 model and answers recorded. 240 single best answer questions (SBAs) (representing the true length of the FRCR 2A examination) were answered by both GPT-3.5 and GPT-4 models. RESULTS: ChatGPT 4 answered 74.8% of part 1 true/false statements correctly. The spring 2023 passing mark of the part 1 examination was 75.5% and ChatGPT thus narrowly failed. In the 2A examination, ChatGPT 3.5 answered 50.8% SBAs correctly, while GPT-4 answered 74.2% correctly. The winter 2022 2A pass mark was 63.3% and thus GPT-4 clearly passed. CONCLUSION: AI models such as ChatGPT are able to answer the majority of questions in an FRCR style examination. It is reasonable to assume that further developments in AI will be more likely to succeed in comprehending and solving questions related to medicine, specifically clinical radiology. ADVANCES IN KNOWLEDGE: Our findings outline the unprecedented capabilities of AI, adding to the current relatively small body of literature on the subject, which in turn can play a role medical training, evaluation and practice. This can undoubtedly have implications for radiology.

A rare case of an intraneural ganglion cyst of the median nerve.

Aim of the study: Intraneural ganglion cysts are a relatively uncommon type of ganglion cyst that can affect peripheral nerves. They are particularly rare in the upper limb, and even more so in the median nerve, with the vast majority of them occurring in the peroneal nerves. This paper aims to make the reader aware of this relatively uncommon condition. Case description: We report a case of a 41-year-old male who presented with a gradually progressing mass on the volar aspect of the wrist extending to the index finger. The nonspecific presentation as well as the rarity of the condition may make diagnosis challenging. The patient was referred for surgical management under a specialist peripheral nerve hand surgeon. Conclusions: Ultrasound and magnetic resonance imaging as well as awareness of the typical imaging features of this entity are crucial in making the correct diagnosis as well as excluding other potential considerations such as neoplasm.

Current role and future applications of image-guided interventional procedures in musculoskeletal oncology - A narrative review.

Background: Musculoskeletal (MSK) image-guided interventional procedures have been increasingly used in and remain crucial in the diagnosis and treatment of musculoskeletal tumours. Aims: In this article, we aim to describe commonly performed interventional procedures in the subspeciality of MSK oncology drawing experience from our tertiary referral centre. Recent advances, emerging techniques and future applications of image-guided interventional procedures in the field of MSK oncology are highlighted. Material and methods: A retrospective search using the keyword 'musculoskeletal system', 'neoplasms', 'biopsy', and 'interventional radiology' was performed at our tertiary care oncology orthopaedic referral centre radiology database. The radiology images were collected from our Picture Archiving and Communication System (PACS) and Radiology Information System (RIS). Electronic Patient Records, histopathology laboratory records and patient characteristics were collaborated to generate this narrative experience at our centre. Results: Image-guided interventional procedures have been utilised in a spectrum of primary and secondary MSK tumours. Current applications include diagnosis of bone and soft tissue MSK neoplastic lesions with biopsies, thermal, cryotherapy and Radiofrequency ablations and augmentation procedures. Conclusion: Musculoskeletal (MSK) image-guided interventions have increasing applications in the diagnosis, management, treatment and monitoring of patients with MSK tumours. The emergence of newer imaging technologies with enhanced skills of interventional radiologists will allow a range of therapeutic MSK interventions in both effective control of primary lesions and palliative care of metastatic lesions.

Primary Benign Neoplasms of the Spine.

Benign tumours comprise the majority of primary vertebral tumours, and these are often found incidentally on imaging. Nonetheless, accurate diagnosis of these benign lesions is crucial, in order to avoid misdiagnosis as more ominous malignant lesions or infection. Furthermore, some of these tumours, despite their benign nature, can have localised effects on the spine including neural compromise, or can be locally aggressive, thus necessitating active management. Haemangiomas and osteomas (enostosis) are the commonest benign tumours encountered. Others include osteoid osteoma, osteoblastoma, fibrous dysplasia, osteochondroma, chondroblastoma, haemangioma, simple bone cysts, aneurysmal bone cysts, giant cell tumours, eosinophilic granuloma and notochordal rests. The majority of lesions are asymptomatic; however, locally aggressive lesions (such as aneurysmal bone cysts or giant cell tumours) can present with nonspecific symptoms, such as back pain, neurological deficits and spinal instability, which may be indistinguishable from more commonly encountered mechanical back pain or malignant lesions including metastases. Hence, imaging, including radiography, computed tomography (CT) and magnetic resonance imaging (MRI), plays a critical role in diagnosis. Generally, most incidental or asymptomatic regions are conservatively managed or may not require any follow-up, while symptomatic or locally aggressive lesions warrant active interventions, which include surgical resection or percutaneous treatment techniques. Due to advances in interventional radiology techniques in recent years, percutaneous minimally invasive techniques such as radiofrequency ablation, sclerotherapy and cryoablation have played an increasing role in the management of these tumours with favourable outcomes. The different types of primary benign vertebral tumours will be discussed in this article with an emphasis on pertinent imaging features.

Primary Osseous Malignancies of the Spine.

Malignant primary vertebral tumours comprise an uncommon group of primary bone malignancies that can pose a diagnostic and therapeutic challenge. The most frequently encountered malignant primary vertebral tumours include chordoma, chondrosarcoma, Ewing sarcoma and osteosarcoma. These tumours often present with nonspecific symptoms, such as back pain, neurologic deficits and spinal instability, which can be confused for the more commonly encountered mechanical back pain and may delay their diagnosis and treatment. Imaging, including radiography, computed tomography (CT) and magnetic resonance imaging (MRI) is crucial for diagnosis, staging, treatment planning and follow-up. Surgical resection remains the mainstay of treatment for malignant primary vertebral tumours, but adjuvant radiotherapy and chemotherapy may be necessary for achieving complete tumour control depending on the type of tumour. In recent years, advances in imaging techniques and surgical approaches, such as en-bloc resection and spinal reconstruction, have improved the outcomes for patients with malignant primary vertebral tumours. However, the management can be complex due to the anatomy involved and the high morbidity and mortality associated with surgery. The different types of malignant primary vertebral lesions will be discussed in this article with an emphasis on the imaging features.