Experience with a frontal core biopsy device in soft tissue and bone lesions.

OBJECTIVE: To assess the efficacy and cost of a new frontloading biopsy system, Spirotome® (system 1), in musculoskeletal lesions, and to compare the results with those obtained with commonly used biopsy devices. METHODS: System 1 was used in all soft tissue lesions (STL) and osteolytic bone lesions (OBL) of patients who presented at our department for CT-guided biopsy between January 2009 and June 2010. Accuracy and cost were compared to those of Bonopty® (system 2) and Tru-cut (system 3) procedures. RESULTS: The efficacy of system 1 was 85% in STL and 89% in OBL. The procedure was well tolerated and caused no complications. System 3 had an efficacy of 84% in STL and OBL combined. The efficacy of system 2 in OBL was 85%. The cost of single-use system 1 and system 2 was comparable, the cost of system 3 and multiuse system 1 compared to single-use system 1 was 25 and 7%, respectively. CONCLUSIONS: The efficacy of system 1 in biopsy of STL and OBL was better than that of system 3. In OBL, the efficacy of system 1 was better than that of system 2. In STL at hazardous locations and small OBL with a thin cortical shell, system 1 offers the advantage of variable length and controlled loading. In these cases, single-use system 1 was cost-effective when compared to surgical biopsy. The cost per procedure of multiuse system 1 was lower than of system 3.

The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys.

PURPOSE: To investigate and compare the opinions and expectations regarding the radiology report of radiologists and referring clinicians and to identify trends, discordance, and discontent. MATERIALS AND METHODS: A total of 3884 clinicians and 292 radiologists were invited by e-mail to participate in two internet surveys, COVER (for clinical specialists and general practitioners) and ROVER (for radiologists). Respondents were asked to state their level of agreement with 46 statements according to a Likert scale. Dichotomized results were compared by using the χ(2) statistic. RESULTS: Eight hundred seventy-three completed forms were prepared for analysis, corresponding to a response rate of 21%. Most clinicians declared themselves satisfied with the radiology report. A large majority considered it an indispensable tool and accepted that the radiologist is the best person to interpret the images. Nearly all agreed that they need to provide adequate clinical information and state clearly what clinical question they want to have answered. Itemized reporting was preferred for complex examinations by both the clinicians and the radiologists. A majority in both groups were convinced that learning to report needs to be taught in a structured way. CONCLUSION: The surveys emphasize the role of the radiologist as a well-informed medical imaging specialist; however, some of the preferences of radiologists and clinicians diverge fundamentally from the way radiology is practiced and taught today, and implementing these preferences may have far-reaching consequences.

Pseudotumoural soft tissue lesions of the hand and wrist: a pictorial review.

Mimickers of soft tissue tumours in the hand and wrist are more frequent than true neoplastic lesions. Pseudotumours belong to a large and heterogeneous group of disorders, varying from normal anatomical variants, cystic lesions, post-traumatic lesions, skin lesions, inflammatory and infectious lesions, non-neoplastic vascular lesions, metabolic disorders (crystal deposition disease and amyloidosis) and miscellaneous disorders. Although the imaging approach to pseudotumoural lesions is often very similar to the approach to "true" soft tissue tumoral counterparts, further management of these lesions is different. Biopsy should be performed only in doubtful cases, when the diagnosis is unclear. Therefore, the radiologist plays a pivotal role in the diagnosis of these lesions. Awareness of the normal anatomy and existence and common imaging presentation of these diseases, in combination with relevant clinical findings (clinical history, age, location and skin changes), enables the radiologist to make the correct diagnosis in most cases, thereby limiting the need for invasive procedures.

How do referring clinicians want radiologists to report? Suggestions from the COVER survey.

OBJECTIVE: To investigate what referring clinicians suggest when asked how the quality of radiology reports can be improved. METHODS: At the end of the questionnaire of the COVER survey, a bi-national quantitative survey on the radiology report among referring physicians, clinical specialists and general practitioners were able to freely enter suggestions with regard to improving the quality of the report. These suggestions were isolated from the quantitative results. Subjects and themes were identified, examined, ordered, counted, compared and analysed. RESULTS: Of a total of 3,884 invitations to participate, we received 735 response forms from clinicians (18.9%), 233 (31.7%) of which contained suggestions. Issues mentioned most frequently were the need for clinical information and a clinical question, for a conclusion, structuring, communicating directly with the clinician, completeness, integrating images or referring to images, mentioning relevant findings outside of the clinical question, mentioning a diagnosis or suitable differential diagnosis, and concise reporting. CONCLUSION: Although these spontaneous suggestions are erratic and sometimes contradictory, they summarise the ideas as well as the emotions of these clients of the radiology department. Therefore it is advisable to take them into account when developing new ways of reporting.

A comparison between histopathology and findings on magnetic resonance imaging of subcutaneous lipomatous soft-tissue tumors.

OBJECTIVE: To retrospectively analyse the magnetic resonance (MR) findings of subcutaneous lipomatous soft-tissue tumours (SLSTT) in order to define a diagnostic and therapeutic strategy. METHODS: The MR findings of 46 SLSTT were registered for the following data: area, location within the subcutaneous compartment, dimensions, shape and delineation, signal intensity (SI) on different pulse sequences, signal homogeneity, degree and pattern of contrast enhancement. The MR findings, together with patients' age and gender, were compared with histopathological findings. RESULTS: Sixty-eight percent of the lipomas had a homogeneous T1-SI identical to the SI of subcutaneous fat. Heterogeneity in other lipomas was due to fat necrosis and small septa. Other lesions with homogeneous T1-SI identical to the SI of subcutaneous fat included lipoblastoma, lipomatosis and lipoma-like hibernoma. None of the liposarcomas were homogeneous and isointense to SI of subcutaneous fat on T1-weighted imaging (WI). Lipoma variants and liposarcomas showed overlapping MR characteristics. CONCLUSIONS: SLSTT with homogeneous T1-SI identical to the SI of subcutaneous fat are benign. If a SLSTT has other MR characteristics, differentiation based on MRI cannot be made and biopsy is needed. We used this finding in defining a diagnostic and therapeutic strategy for subcutaneous soft tissue tumours that are hyperintense on T1-WI.

Soft tissue tumors: grading, staging, and tissue-specific diagnosis.

The value of medical imaging in detection, staging, grading, and tissue-specific diagnosis has been substantially increased, especially after the introduction of magnetic resonance imaging, the combined use of cytogenetic and molecular techniques and the refinement of biopsy techniques. In this paper, we will focus on the combination of parameters including clinical information, prevalence, age, location, and findings on medical imaging, yielding the highest diagnostic sensitivity and specificity. An imaging prototype of a malignant soft tissue tumor will be proposed. In a second part, we will present an overview of most common soft tissue tumors, especially focusing on these tumors having more characteristic imaging features that allow to make a more detailed tissue-specific diagnosis. Finally, we will give the radiologist a short list of important things to take home.

Accuracy of MRI in characterization of soft tissue tumors and tumor-like lesions. A prospective study in 548 patients.

The purpose of our study was to assess prospectively the value of MRI in characterization of soft tissue tumors (STT) and soft tissue tumor-like lesions in a multi-institutional setting by a group of experts. The material consisted of 548 untreated and proven STT or tumor-like lesions originating from a multi-institutional database of STT in which 930 consecutive patients with STT examined by MRI were registered between 1 January 2001 and 28 April 2003. Based on MRI findings, a suitably ordered differential diagnosis was made in consensus by two radiologists (J.L.M.A.G and A.M.D.S). MRI diagnoses were compared with histology results (455 cases, 83%) and/or 6-month follow-up (93 cases, 17%) as reference standards. The correlation between the MRI and histological diagnosis and between the radiological and histological phenotype were statistically determined. One hundred twenty-three patients presented with a malignant STT; 425 patients presented with a benign one. Concerning differentiation between malignant and benign lesions (dignity), a sensitivity of 93%, specificity of 82%, negative predictive value (NPV) of 98% and positive predictive value (PPV) of 60% with accuracy of 85% were obtained. Concerning phenotype characterization, if only the first MRI diagnosis was taken into account, a sensitivity of 67%, specificity of 98%, NPV of 98%, PPV of 70% and accuracy of 96% were obtained. For benign lesions, sensitivity of 75%, specificity of 98%, NPV of 98%, PPV of 76% and accuracy of 97% were obtained. The phenotype's definition of malignant STT had a sensitivity of 37%, a specificity of 96%, NPV of 96%, PPV of 40% and an accuracy of 92%. A correct diagnosis compared with histological assessment was proposed in 227(50%) of the 455 histologically confirmed cases. Despite non-quantified MR parameter evaluation, the results of our prospective study were better than those reported in previous studies and demonstrated the need for a centralized approach to such rare pathology.

The interutricular distance determined from external landmarks.

Knowledge of the exact distance between the utricles is important in new vestibular tests, such as the unilateral centrifugation (UC) test for the unilateral examination of the utricles. During this test, subjects are rotated at constant velocity and simultaneously laterally displaced along an interaural axis so that one labyrinth becomes aligned with the axis of rotation. When the axis of rotation crosses precisely through one labyrinth, only the opposite labyrinth is stimulated. To achieve this setup, precise knowledge of the interutricular distance is needed. The purpose of this study is to investigate the correlation between the interutricular distance (IUD), measured on T2-weighted magnetic resonance images, and specific external measures of head dimensions such as distance nasion-inion, intermastoid distance (IMD), distances between the temporomandibular joints and between the lateral margins of the orbits. Data have been collected in a series of 50 subjects (25 men and 25 women). On MR images we found a mean IUD of 7.22 cm (SD = 0.42 cm). There was a strong correlation between the IUD measured on MR images and the intermastoid distance. A linear combination of the IMD, nasion-inion distance and height of the subjects could predict the IUD very satisfactory (R = 0.85, adjusted R2=0.723). We also determined a measure of eccentricity of the vestibular labyrinths. The 95% prediction interval for the asymmetry appeared to be less than 4.3%.

Van Buchem disease: lifetime evolution of radioclinical features.

OBJECTIVE: The purpose of this study was to evaluate the lifetime evolution of the radioclinical features in a large family with van Buchem disease. DESIGN AND PATIENTS: The study population included 13 patients, ranging between 6 and 69 years. The evolution of the clinical features has been assessed by retrospective analysis of the clinical records of the patients. The age-related evolution of the cortical hyperostosis and defective modeling at the tubular bones was evaluated by morphometric analysis of hand films in 9 patients, compared with 9 control individuals. Progression of sclerosis of the craniofacial bones was evaluated by analysis of the skull radiographs of eleven van Buchem patients, taken at different age. RESULTS AND CONCLUSIONS: Radioclinical features, including sclerosis of the cranial and tubular bones and cranial nerve deficit, become more prominent in older patients. Defective modeling of tubular bones, cortical thickness and medullary width progress with age. Radioclinical abnormalities of van Buchem patients become more prominent in older patients, which suggests that the van Buchem gene is very actively involved in bone metabolism throughout life. Morphometric analysis of the plain films supports the hypothesis that the physiological function of the van Buchem gene is to inhibit bone formation and possibly to regulate bone remodeling.

Imaging features of musculoskeletal tuberculosis.

The purpose of this article is to review the imaging characteristics of musculoskeletal tuberculosis. Skeletal tuberculosis represents one-third of all cases of tuberculosis occurring in extrapulmonary sites. Hematogenous spread from a distant focus elsewhere in the body is the cornerstone in the understanding of imaging features of musculoskeletal tuberculosis. The most common presentations are tuberculous spondylitis, arthritis, osteomyelitis, and soft tissue involvement. The diagnostic value of the different imaging techniques, which include conventional radiography, CT, and MR imaging, are emphasized. Whereas conventional radiography is the mainstay in the diagnosis of tuberculous arthritis and osteomyelitis, MR imaging may detect associated bone marrow and soft tissue abnormalities. MR imaging is generally accepted as the imaging modality of choice for diagnosis, demonstration of the extent of the disease of tuberculous spondylitis, and soft tissue tuberculosis. Moreover, it may be very helpful in the differential diagnosis with pyogenic spondylodiscitis, as it may easily demonstrate anterior corner destruction, the relative preservation of the intervertebral disk, multilevel involvement with or without skip lesions, and a large soft tissue abscess, as these are all arguments in favor of a tuberculous spondylitis. On the other hand, CT is still superior in the demonstration of calcifications, which are found in chronic tuberculous abscesses.

Brainstem hemorrhage in descending transtentorial herniation (Duret hemorrhage).

OBJECTIVES: To review clinical and radiological findings in patients with Duret hemorrhages and to discuss the pathophysiology and differential diagnosis of these lesions. PATIENTS AND METHODS: We reviewed the case records of four patients with Duret hemorrhages who had been admitted to the neurological intensive care unit with supratentorial mass lesions. RESULTS: Descending transtentorial and subfalcine herniations were present in all cases. Three patients were admitted with acute subdural hematoma and one with intraparenchymal hemorrhage. Computed tomography revealed the presence of blood in the mesencephalon and upper pons. Three patients died; one survived with severe disabilities. DISCUSSION: Duret hemorrhages are typically located in the ventral and paramedian aspects of the upper brainstem (mesencephalon and pons). The pathophysiology of Duret hemorrhage remains under debate: arterial origin (stretching and laceration of pontine perforating branches of the basilar artery), versus venous origin (thrombosis and venous infarction). Multifactorial causation seems likely. CONCLUSION: Duret hemorrhages are delayed, secondary brainstem hemorrhages. They occur in craniocerebral trauma victims with rapidly evolving descending transtentorial herniation. Diagnosis is made on computed tomography of the brain. In most cases the outcome is fatal. On the basis of our observations we believe that arterial hypertension and advanced age are risk factors for the development of Duret hemorrhage.