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.

Sarcopenia, More Than Just Muscle Atrophy: Imaging Methods for the Assessment of Muscle Quantity and Quality.

BACKGROUND: Sarcopenia, a progressive reduction of muscle mass and function, is associated with adverse outcomes in the elderly. Sarcopenia and muscle atrophy are not equal processes. Low muscle strength in association with muscle quantity/quality reduction is currently the optimal method for assessing sarcopenia. There is a practical need for indirect measurement of muscle strength using state-of-the-art imaging techniques. METHODS: The following provides a narrative, broad review of all current imaging techniques for evaluating muscles and identifying sarcopenia, including DEXA, CT, MRI, and high-resolution ultrasound, their main strengths, weaknesses, and possible solutions to problems regarding each technique. RESULTS AND CONCLUSION: Well-recognized imaging methods for the assessment of muscle mass are explained, including evaluation with DEXA, CT, and MRI muscle quantity assessment, ultrasound evaluation of muscle thickness and CSA, and their correlations with established muscle mass calculation methods. A special focus is on imaging methods for muscle quality evaluation. Several innovative and promising techniques that are still in the research phase but show potential in the assessment of different properties of muscle quality, including MRI DIXON sequences, MRI spectroscopy, Diffusion Tensor Imaging, ultrasound echo intensity, ultrasound elastography, and speed-of-sound ultrasound imaging are briefly mentioned. KEY POINTS: · Sarcopenia definition includes low muscle strength and low muscle quantity/quality.. · DEXA is a low-radiation method for whole-body composition measurement in a single image.. · CT has established cut-off values for muscle quality/quantity evaluation and sarcopenia diagnosis.. · MRI is the most sophisticated muscle quality assessment method capable of evaluating myosteatosis, myofibrosis, and microstructure.. · Ultrasound can evaluate muscle quality, including tissue architecture, and elasticity with excellent spatial resolution.. CITATION FORMAT: · Vasilevska Nikodinovska V, Ivanoski S, . Sarcopenia, More Than Just Muscle Atrophy: Imaging Methods for the Assessment of Muscle Quantity and Quality. Fortschr Röntgenstr 2023; 195: 777 - 789.

Ultrasound-guided Biopsy of Musculoskeletal Soft-tissue Tumors: Basic Principles, Usefulness and Limitations.

The aim of this article is to provide a short review of the literature concerning the basic principles, usefulness and limitations of ultrasound-guided biopsy of musculoskeletal soft-tissue tumors, with particular focus on core needle biopsies. Musculoskeletal soft-tissue tumors represent a rare and complex group of heterogeneous lesions. Prompt diagnosis of these uncommon lesions can improve the outcome and increase the patient survival rate. A biopsy examination of soft-tissue tumors with imaging modalities is necessary in all cases of aggressive or undetermined lesions. Although fine needle aspiration can be helpful for the biopsy of certain tumor types, core needle biopsy is a standard procedure in most tertiary sarcoma centers. It has a high diagnostic accuracy, low complication rate and lower price in comparison to open biopsy, and can replace it in the majority of cases of soft-tissue tumor assessment. However, the examining physician has to be familiar with the technique, and the strengths and potential difficulties in performing ultrasound-guided biopsy, as well as possible solutions to obstacles. Several recently developed ultrasound techniques can be helpful and improve the outcome of imaging-guided biopsies of musculoskeletal lesions.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part V, knee.

OBJECTIVES: Interventional procedures around the knee are widely adopted for treating different musculoskeletal conditions. A panel of experts from the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the existing literature to assess the evidence on image-guided musculoskeletal interventional procedures around the knee, with the goal of highlighting some controversies associated with these procedures, specifically the role of imaging guidance, as well as the efficacy of the medications routinely injected. METHODS: We report the results of a Delphi-based consensus of 53 experts in musculoskeletal radiology, who reviewed the published literature for evidence on image-guided interventional procedures around the knee to derive a list of pertinent clinical indications. RESULTS: A list of 10 statements about clinical indications of image-guided procedures around the knee was created by a Delphi-based consensus. Only two of them had the highest level of evidence; all of them received 100% consensus. CONCLUSIONS: Ultrasonography guidance is strongly recommended for intra-articular and patellar tendinopathy procedures to ensure the precision and efficacy of these treatments. Prospective randomized studies remain warranted to better understand the role of imaging guidance and assess some of the medications used for interventional procedures around the knee. KEY POINTS: • A list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the knee was produced by an expert panel of the ESSR. • Strong consensus with 100% agreement was obtained for all statements. • Two statements reached the highest level of evidence, allowing us to strongly recommend the use of ultrasonography to guide intra-articular and patellar tendon procedures to ensure higher accuracy and efficacy of these treatments.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb.

OBJECTIVES: To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper. RESULTS: Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. CONCLUSION: Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures. KEY POINTS: • Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle.

OBJECTIVES: Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval. RESULTS: A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement. CONCLUSION: According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton's neuroma, particularly using platelet-rich plasma and corticosteroids, respectively. KEY POINTS: • The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle. • Strong consensus was obtained for all statements. • The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton's neuroma and PRP for plantar fasciitis.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part IV, hip.

OBJECTIVES: Image-guided musculoskeletal interventional procedures around the hip are widely used in daily clinical practice. The need for clarity concerning the actual added value of imaging guidance and types of medications to be offered led the Ultrasound and the Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) to promote, with the support of its Research Committee, a collaborative project to review the published literature on image-guided musculoskeletal interventional procedures in the lower limb in order to derive a list of clinical indications. METHODS: In this article, we report the results of a Delphi-based consensus of 53 experts who reviewed the published literature for evidence on image-guided interventional procedures offered in the joint and soft tissues around the hip in order of their clinical indications. RESULTS: Ten statements concerning image-guided treatment procedures around the hip have been collected by the panel of ESSR experts. CONCLUSIONS: This work highlighted that there is still low evidence in the existing literature on some of these interventional procedures. Further large prospective randomized trials are essential to better confirm the benefits and objectively clarify the role of imaging to guide musculoskeletal interventional procedures around the hip. KEY POINTS: • Expert consensus produced a list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the hip. • The highest level of evidence was only reached for one statement. • Strong consensus was obtained for all statements.

Percutaneous Imaging-Guided versus Open Musculoskeletal Biopsy: Concepts and Controversies.

Bone and soft tissue tumors are a largely heterogeneous group of tumors. Biopsy of musculoskeletal (MSK) tumors is sometimes a challenging procedure. Although the open biopsy is still considered the gold standard for the biopsy of MSK lesions, core needle biopsy can replace it in most cases, with similar accuracy and a low complication rate. The biopsy should be performed in a tertiary sarcoma center where the multidisciplinary team consists of at minimum a tumor surgeon, an MSK pathologist, and an MSK radiologist who can assess all steps of the procedure. Several factors can influence the success of the biopsy including the lesion characteristics, the equipment, and the method used for the procedure. This review highlights some of the important aspects regarding the biopsy of the MSK tumors, with special attention to imaging a guided core needle biopsy and highlighting some of the recent advancements and controversies in the field.

Future Ultrasound Biomarkers for Sarcopenia: Elastography, Contrast-Enhanced Ultrasound, and Speed of Sound Ultrasound Imaging.

Sarcopenia is the advanced and generalized loss of muscle mass and strength among the elderly population and is a cause of adverse outcomes. Methods used for the diagnosis of sarcopenia are either unavailable or expensive in everyday clinical settings. Ultrasound presents an inexpensive, convenient, and available method that offers advantages for the evaluation of skeletal muscle. Muscle quality will probably be the most important factor in defining sarcopenia in the future. Different features of muscle quality, including muscle elasticity, microcirculation and muscle perfusion during rest and physical activity, and the content of intramuscular adipose tissue can be measured using emerging and promising ultrasound techniques such as elastography, contrast-enhanced imaging, and speed of sound ultrasound technology. This article reviews the recent evidence on the use of ultrasound techniques in the assessment of muscle quality and the possibilities for the future evaluation of sarcopenia.

Sonographic assessment of the anatomy and common pathologies of clinically important bursae.

High-resolution ultrasonography has many advantages in the imaging of the musculoskeletal system, when compared to other imaging methods, particularly in superficial, easily accessible parts of the body. It is a perfect diagnostic tool for visualizing the most common pathologies of the musculoskeletal system, including the bursae. Inflammation of bursae is frequent, and it can mimic other diseases of the musculoskeletal system. Therefore, knowledge of normal ultrasound anatomy of the bursae, their exact location in the human body, and the sonographic signs of their most common pathologies is essential for establishing a quick and accurate diagnosis by ultrasound. Common conditions affecting bursae, leading to bursitis, include acute trauma, overuse syndromes, degenerative diseases, inflammatory conditions (rheumatoid arthritis, psoriatic arthritis, gout etc.), infections such as tuberculosis, synovial tumors and tumor-like conditions (pigmented villonodular synovitis, osteochondromatosis), and many more. This review article presents and explains ultrasound examples of the most frequent pathological conditions affecting bursae. Images include normal and pathological conditions of bursae around the shoulder joint, elbow, hip, knee, and ankle joint.

Imaging of juvenile spondyloarthritis. Part I: Classifications and radiographs.

Juvenile spondyloarthropathies are manifested mainly by symptoms of peripheral arthritis and enthesitis. By contrast with adults, children rarely present with sacroiliitis and spondylitis. Imaging and laboratory tests allow early diagnosis and treatment. Conventional radiographs visualize late inflammatory lesions and post-inflammatory complications. Early diagnosis is possible with the use of ultrasonography and magnetic resonance imaging. The first part of the article presents classifications of juvenile spondyloarthropathies and discusses their radiographic presentation. Typical radiographic features of individual types of juvenile spondyloarthritis are listed (including ankylosing spondylitis, juvenile psoriatic arthritis, reactive arthritis and arthritis in the course of inflammatory bowel diseases). The second part will describe changes visible on ultrasonography and magnetic resonance imaging. In patients with juvenile spondyloarthropathies, these examinations are conducted to diagnose inflammatory lesions in peripheral joints, tendon sheaths, tendons and bursae. Moreover, magnetic resonance imaging also visualizes early inflammatory changes in the axial skeleton and subchondral bone marrow edema, which is considered an early sign of inflammation.