Hand and finger, ultrasound-guided, percutaneous core needle biopsies: A safe procedure with high diagnostic accuracy.

Introduction/Purpose: To determine the diagnostic accuracy and complication rates of ultrasound-guided, percutaneous core needle biopsies of soft tissue masses in the hand and fingers. Methods: Reports from all ultrasound-guided procedures between 21 May 2014 and 17 March 2022 were queried for keywords including "hand", OR "finger", AND "biopsy". Patient demographics, lesion size and location, biopsy needle gauge and the number of cores obtained were recorded. The final pathology of the mass excision was then compared with the core needle biopsy (CNB) for each patient. Results: Sixty-six records were reviewed, and 37 patients met inclusion criteria. Maximum lesion diameter averaged 1.45 cm with a range between 0.4 and 4.3 cm. The frequency of needle gauges used was 14G (14%), 16G (24%), 18G (38%), 20G (11%) and 'not reported' (14%). The mean number of tissue cores obtained was 2.9 (SD 1.2; range 1 to 6), excluding nine cases that reported 'multiple'. The frequency of CNB diagnoses included tenosynovial giant cell tumour (TGCT) at 30%, ganglion cyst at 11% and epidermal inclusion cyst at 5%. CNB was 100% sensitive in detecting the three (8%) malignancies. Of the 37 tumours biopsied, 16 were surgically excised. One angiomyoma was originally diagnosed as a haemangioma on CNB, but all other histologic results were concordant for a diagnostic accuracy of 97%. Discussion: Small soft tissue masses in the hands and fingers, even those less than 1 cm, are often amenable to ultrasound-guided CNB. Performance under image guidance facilitates retrieval of core specimens adquate for histologic diagnosis with relatively few passes using higher gauge needles. Conclusion: Overall, ultrasound-guided CNB of the hand and fingers is safe and highly accurate in diagnosing soft tissue tumours. The accuracy is unrelated to the needle's gauge, the number of passes and the size of the lesions.

Benign Bone Lesions Found in Childhood.

Benign bone tumors are a wide variety of usually asymptomatic neoplasms, which in most cases are diagnosed due to secondary causes. As such, their real incidence is unknown. In the majority of cases, plain radiographs are enough for diagnosis; more advanced imaging, such as CT scan or MRI is sometimes performed for equivocal lesions. Treatment approach depends on whether the lesion is symptomatic and the risk of further progression, or development of secondary malignancies. When non expectant management is decided, treatment options include minimally invasive methods and surgery.

MRI T2 mapping assessment of T2 relaxation time in desmoid tumors as a quantitative imaging biomarker of tumor response: preliminary results.

Objectives: Because size-based imaging criteria poorly capture biologic response in desmoid-type fibromatosis (DF), changes in MRI T2 signal intensity are frequently used as a response surrogate, but remain qualitative. We hypothesized that absolute quantification of DF T2 relaxation time derived from parametric T2 maps would be a feasible and effective imaging biomarker of disease activity. Methods: This IRB-approved retrospective study included 11 patients with DF, managed by observation or systemic therapy, assessed by 3T MRI. Tumor maximum diameter, volume, and T2-weighted signal intensity were derived from manual tumor segmentations. Tumor:muscle T2 signal ratios were recorded. Two readers measured tumor T2 relaxation times using a commercial T2 scanning sequence, manual ROI delineation and commercial calculation software enabling estimation of reader reliability. Objective response rates based on RECIST1.1 and best responses were compared between size-based and signal-based parameters. Results: Median patient age was 52.6 years; 8 subjects were female (73%). Nine patients with longitudinal assessments were followed for an average of 314 days. Median baseline tumor diameter was 7.2 cm (range 4.4 - 18.2 cm). Median baseline T2 was 65.1 ms (range 40.4 - 94.8 ms, n=11); median at last follow-up was 44.3 ms (-32% from baseline; range 29.3 - 94.7 ms, n=9). T2 relaxation times correlated with tumor:muscle T2 signal ratios, Spearman p=0.78 (p<0.001). T2 mapping showed high inter-reader reliability, ICC=0.84. The best response as a percentage change in T2 values was statistically significant (mean -17.9%, p=0.05, paired t-test) while change in diameter was not (mean -8.9%, p=0.12). Conclusions: Analysis of T2 relaxation time maps of DF may offer a feasible quantitative biomarker for assessing the extent of response to treatment. This approach may have high inter-reader reliability.

Radiologic screening and surveillance in hereditary cancers.

Hereditary cancer syndromes comprise an important subset of cancers caused by pathogenic germline mutations that can affect various organ systems. Radiologic screening and surveillance for solid tumors has emerged as a critical component of patient management in permitting early cancer detection. Although imaging surveillance may be tailored for organ-specific cancer risks, surveillance protocols frequently utilize whole-body MRI or PET/CT because of their ability to identify neoplasms in different anatomic regions in a single exam. In this review, we discuss the basic tenets of imaging screening and surveillance strategies in these syndromes, highlighting the more common neoplasms and their associated multimodality imaging findings.

Musculoskeletal Metastasis From Soft-tissue Sarcomas: A Review of the Literature.

Soft-tissue sarcomas are a rare and extremely heterogeneous group of cancers, representing <1% of all human malignancies. The lungs are the most common site of distant metastasis, followed by the bone, lymph nodes, liver, brain, and subcutaneous tissue. Clinical experience suggests that skeletal metastasis is part of the natural history affecting the prognosis and quality of life in these patients. Approximately 2.2% of patients have skeletal metastasis at diagnosis. However, up to 10% will develop skeletal metastasis after a mean interval of 21.3 months. Although systemic therapy with conventional chemotherapy remains the primary treatment modality for those with metastatic sarcoma, increased survival has been achieved in selected patients who receive multimodality therapy, including surgery, for their metastatic disease. The 5-year overall survival of patients with isolated bone metastases was 41.2% (26.9% to 54.9%), which decreased to 32.9% (21.2% to 45.1%) in the setting of combined bone and lung metastases. Moreover, the resection of the primary soft-tissue sarcoma is a predictor of survival, resulting in a 58% decrease in mortality after surgery (hazard ratio, 0.42, P = 0.013). Understanding the effect of these metastases on patient survival may influence imaging, surveillance, and treatment decisions.

Soft Tissue Tumors: Imaging Features of Primary Soft Tissue Malignancies.

Imaging in soft tissue sarcomas (STS) plays a key role in diagnosis, surgical planning, and assessment of treatment response, and surveillance. In this review, we discuss the imaging features-with an emphasis on MR imaging-of nonvisceral STS, highlighting representative tumors from the various WHO subtypes. We focus on imaging findings that may aid the radiologist in categorizing tumor subtype and grade, and that affect disease staging.

Systemic Chemotherapies Retain Antitumor Activity in Desmoid Tumors Independent of Specific Mutations in CTNNB1 or APC: A Multi-institutional Retrospective Study.

PURPOSE: Determine whether specific CTNNB1 or APC mutations in patients with desmoid tumor were associated with differences in clinical responses to systemic treatments. EXPERIMENTAL DESIGN: We established a multi-institutional dataset of previously treated patients with desmoid tumor across four U.S. sarcoma centers, including demographic and clinicopathologic characteristics, treatment regimens, and clinical and radiographic responses. CTNNB1 or APC mutation status was determined from prior pathology records, or archival tissue was requested and analyzed by Sanger sequencing and/or next-generation sequencing. Evaluable patients with mutation results were analyzed to determine clinical progression-free survival (cPFS), RECIST 1.1 PFS (rPFS), time to next treatment (TTNT), and overall survival (OS). Kaplan-Meier analysis and Cox proportional hazards regression were performed to identify differences in cPFS, rPFS, TTNT, and OS by mutation subtype, desmoid tumor location, and treatment regimen. RESULTS: A total of 259 evaluable patients were analyzed for at least one of the survival outcomes, with 177 patients having mutation data. First- and second-line cPFS, rPFS, and TTNT were not significantly affected by mutation subtype; however, APC-mutant desmoid tumors demonstrated nonstatistically significant inferior outcomes. Extremity/trunk desmoid tumor location and treatment with doxorubicin-based, methotrexate/vinca alkaloids and sorafenib regimens were associated with better clinical outcomes compared with surgery or "other" therapies, including estrogen-receptor blockade and imatinib. OS was significantly worse with APC or CTNNB1 negative/other mutations. CONCLUSIONS: Mutation subtype did not affect responses to specific systemic therapies. APC mutations and nonextremity desmoid tumor locations remain prognostic for worse outcomes, and earlier initiation of systemic therapy for these higher-risk desmoid tumors should be prospectively evaluated. See related commentary by Greene and Van Tine, p. 3911.

Systematic review: investigating the added diagnostic value of gadolinium contrast agents for osteomyelitis in the appendicular skeleton.

OBJECTIVE: Osteomyelitis is an infection of the bone marrow. MRI with gadolinium-based contrast is frequently performed for cases of suspected osteomyelitis. The objective of this systematic review is to examine the diagnostic accuracy of contrast-enhanced vs non-contrast-enhanced MRI for osteomyelitis in the appendicular skeleton. MATERIALS AND METHODS: We conducted a systematic review of MRI in the diagnosis of osteomyelitis by searching MEDLINE and EMBASE from January 2000 to March 2020. There were 21 studies that met the inclusion criteria for the systematic review for a total of 1095 patients. Analytic methods were based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Evidence was evaluated using the STARD criteria for evaluation of completeness and transparency of reporting. RESULTS: For diagnosing osteomyelitis in the appendicular skeleton, MRI with gadolinium-based contrast has 89% sensitivity (95% CI, 86-92%), 79% specificity (95% CI, 75-83%), and 90% overall diagnostic accuracy ([SE] = 0.03). For diagnosing osteomyelitis in the appendicular skeleton, MRI without gadolinium-based contrast has a 92% sensitivity (95% CI, 87-96%), 89% specificity (95% CI, 84-93%), and 96% overall diagnostic accuracy ([SE] = 0.03). The median score of included studies was 85% utilizing the STARD criteria with excellent interobserver agreement of 83.4%. Limitations included small sample size of studies, with retrospective designs. CONCLUSION: No evidence was found to suggest an added diagnostic value of gadolinium contrast for the diagnosis of osteomyelitis in the appendicular skeleton. For routine cases of suspected non-spinal osteomyelitis, non-contrast MRI of the area of interest is the next most appropriate study after radiographs.

PET-CT in the Evaluation of Neoadjuvant/Adjuvant Treatment Response of Soft-tissue Sarcomas: A Comprehensive Review of the Literature.

➢: In soft-tissue sarcomas (STSs), the use of positron emission tomography-computed tomography (PET-CT) through a standardized uptake value reduction rate correlates well with histopathological response to neoadjuvant treatment and survival. ➢: PET-CT has shown a better sensitivity to diagnose systemic involvement compared with magnetic resonance imaging and CT; therefore, it has an important role in detecting recurrent systemic disease. However, delaying the use of PET-CT scan, to differentiate tumor recurrence from benign fluorodeoxyglucose uptake changes after surgical treatment and radiotherapy, is essential. ➢: PET-CT limitations such as difficult differentiation between benign inflammatory and malignant processes, inefficient discrimination between benign soft-tissue tumors and STSs, and low sensitivity when evaluating small pulmonary metastases must be of special consideration.

Radiographic Evaluation of Elbow Fractures.

Fractures and dislocations of the elbow are a common cause of emergency department visits each year. Radiography remains the bedrock of an initial injury assessment, and recognition of distinctive injury patterns based on fracture location, morphology, and severity, guides optimal clinical decision-making. This article reviews basic elbow anatomy, frequently seen fractures and injury patterns, and highlights how these findings influence surgical planning and patient management.

MRI Volumetrics and Image Texture Analysis in Assessing Systemic Treatment Response in Extra-Abdominal Desmoid Fibromatosis.

Purpose To determine whether MRI volumetric and image texture analysis correlates with treatment-induced biologic changes in desmoid fibromatosis (DF) earlier than conventional response criteria. Materials and Methods This retrospective study included 27 patients with histologically proven extra-abdominal DF who were managed with active surveillance or systemic therapy (from 2004 to 2016). MRI volumetric and image texture parameters were derived from manual tumor segmentations, and tumor signal intensity was normalized to muscle. Results were compared with objective response rates based on Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, World Health Organization (WHO) lesion response, volumetrics, and MRI-modified Choi criteria. Correlation coefficients (r) between image texture features and maximum tumor diameters were obtained by using a meta-analysis approach. Results The 27 included patients (mean age, 39 years; 74% women) were followed for an average of 4 years, comprising 207 distinct time-point assessments. The mean baseline tumor maximum diameter was 7.9 cm (range, 3.4-15.2 cm). Partial response (PR) rates as best response were 37%, 44%, 70%, and 81% by RECIST, WHO, volumetrics, and MRI-modified Choi criteria, respectively. Among the 10 tumors showing RECIST PR, a preceding MRI-modified Choi PR was observed in 70% (seven of 10), on average 1.3 years earlier. Multiple image texture parameters showed associations with objective measurements of tumor diameter including mean tumor-to-muscle signal ratio (r = 0.51; P = .004), median tumor-to-muscle signal ratio (r = 0.52; P = .003), energy (r = 0.48; P < .001), run entropy (r = 0.32, P = .04), and gray-level nonuniformity (r = 0.54; P ≤ .001). Conclusion Volumetric signal and image texture assessment allows more comprehensive analysis of DF biologic change and may permit early prediction of DF behavior and therapeutic response. Keywords: MR Imaging, Soft Tissues/Skin, Neoplasms-Primary © RSNA, 2021.

Septic Arthritis of the Shoulder After SARS-CoV-2 Pfizer Vaccination: A Case Report.

CASE: We report a case of a 68-year-old woman who developed left shoulder glenohumeral joint septic arthritis within 1 week of receiving the COVID-19 Pfizer-BioNTech vaccine. CONCLUSION: Common vaccine complications include injection site pain, fever, chills, arthralgia, and hypersensitivity reactions. A less common and more serious complication of septic arthritis has been reported and requires invasive treatment of surgical irrigation and debridement, and culture-specific parenteral antibiotic therapy. The current report highlights the clinical presentation and significant potential for serious complication with the improper technique. We urge vaccine administrators to practice caution and aseptic technique when vaccinating patients to reduce the risk of complication and morbidity.

Superficial fibromatosis: MRI radiomics and T2 mapping correlate with treatment response.

BACKGROUND: Superficial fibromatosis exhibits variable MR signal intensity due to collagenous and fibroproliferative components. Quantifying this signal heterogeneity using image texture analysis and T2-mapping could have prognostic and therapeutic implications. METHODS: This IRB-approved retrospective study included 13 patients with superficial fibromatosis, managed by observation, electron beam radiotherapy (EBT), or pentoxifylline/vitamin E. Two-dimensional regions of interest (ROIs) were drawn on proton-density or T2-weighted MRI for radiomics feature analysis, and corresponding T2-maps. Comparisons were made between baseline and follow-up T2 relaxation times and radiomics features: Shannon's entropy, kurtosis, skewness, mean of positive pixels (MPP), and uniformity of distribution of positive gray-level pixel values (UPP). RESULTS: There were 19 nodules in 13 subjects. Mean patient age was 60 years; 62% (8/13) were female; mean follow-up was 9.7 months. Nodule diameter at baseline averaged 18.2 mm (std dev 16.2 mm) and decreased almost 10% to 16.6 mm (p = 0.1, paired t-test). Normalized T2 signal intensity decreased 23% from 0.71 to 0.55 (p = 0.03, paired t-test). T2 relaxation time decreased 16% from 46.5 to 39.1 ms (p < 0.001, paired t-test). Among radiomics features, skewness increased to 0.71 from 0.41 (p = 0.03, paired t-test), and entropy decreased from 8.37 to 8.03 (p = 0.05, paired t-test); differences in other radiomics features were not significant. CONCLUSIONS: Radiomics analysis and T2-mapping of superficial fibromatosis is feasible; robust decreases in absolute T2 relaxation time, and changes in image textural features (increased skewness and decreased entropy) offer novel imaging biomarkers of nodule collagenization and maturation.

Differential diagnosis of T2 hypointense masses in musculoskeletal MRI.

Many soft tissue masses have an indeterminate appearance on MRI, often displaying varying degrees and extent of T2 hyperintensity. However, a subset of neoplasms and tumor-like lesions may exhibit prominent areas of T2 hypointensity relative to skeletal muscle. The hypointensity observed on T2-weighted MRI can be caused by a variety of substances, including evolving blood products, calcifications or other inorganic crystals, or fibrous tissue. Carefully evaluating the presence and pattern of T2 hypointensity in soft tissue masses and considering potential causes in their associated clinical contexts can help to narrow the differential diagnosis among neoplastic and non-neoplastic possibilities. These include endometriosis, aneurysmal bone cysts, tenosynovial giant cell tumor, arteriovenous malformation and pseudoaneurysm, calcium pyrophosphate and hydroxyapatite deposition diseases, tumoral calcinosis, gout, amyloidosis, hemangiomas with phleboliths, low-grade fibromyxoid sarcoma, ossifying fibromyxoid tumor, collagenous fibroma, desmoid-type fibromatosis, myxofibrosarcoma, peripheral nerve sheath tumors, dedifferentiated liposarcoma, and treated sarcoma.

Immunohistochemical Characterization of Giant Cell Tumor of Bone Treated With Denosumab: Support for Osteoblastic Differentiation.

Giant cell tumor of bone is a locally aggressive, rarely metastasizing neoplasm. Evidence suggests that the neoplastic cells may be osteoblastic in differentiation. Standard treatment is surgical removal, but medical therapy with denosumab, an inhibitor of receptor activator of nuclear factor-κß ligand, has become a component of patient management in select cases. Denosumab-treated giant cell tumor of bone (DT-GCTB) shows drastic morphologic changes including the presence of abundant bone. To further determine the relationship of the neoplastic cells to osteoblast phenotype, we performed a morphologic and immunohistochemical study on a series of DT-GCTB. Cases of DT-GCTB were retrieved from surgical pathology files, available slides were reviewed, and immunohistochemistry for H3.3 G34W, SATB2, and p63 was performed. The cohort included 31 tumors from 30 patients (2:3 male:female), ages 15 to 73 years (median=36 y). The morphology of post-denosumab-treated tumors ranged from tumors composed of an abundant bone matrix with few spindle cells to spindle cell-predominant tumors. Five had focal residual classic CGTB, and 2 manifested mild nuclear atypia. The majority expressed all markers: 86.2% for H3.3 G34W, 96.7% for SATB2, and 100% for p63. All markers stained the various tumor components including spindle cells and the cells on the surface of and within the treated tumor bone matrix. Most markers were also positive in reactive-appearing woven bone adjacent to tumor: 84.6% for H3.3 G34W, 100% for SATB2, and 68% for p63. These findings suggest that denosumab treatment of giant cell tumor of bone results in osteoblastic differentiation with bone production.

Musculoskeletal MRI of Nontraumatic Emergencies.

A wide range of nontraumatic musculoskeletal conditions may require emergent or urgent management to avoid adverse clinical outcomes. These entities include bone and soft tissue infections, tissue necrosis, impending pathologic fracture or fungating tumor, and pseudoaneurysms. In this review, the magnetic resonance imaging appearance of these various entities is presented and discussed with the aim of improving radiologist and clinician recognition of the importance of key imaging findings in each case.

Measuring and Teaching Confidence Calibration Among Radiologists: A Multi-Institution Study.

OBJECTIVE: Our purpose was to assess the calibration of resident, fellow, and attending radiologists on a simple image classification task (presence or absence of an anterior cruciate ligament [ACL] tear based on interpretation of sagittal proton density, fat-saturated MR images) and to assess whether teaching residents could improve their calibration. METHODS: We created a test containing 30 randomized, sagittal, proton density, fat-saturated MR images of the ACL (15 normal, 15 torn). This test was administered in person to 20 trainees and 3 attendings at one medical center in one state. An online version of the test was given to 23 trainees and 14 attendings from 11 other medical centers in nine other states. Subjects were asked to give their confidence level (0%-100%) that each ACL was torn. RESULTS: Cross-sectional data were collected from 60 radiologists (mean time after medical school = 9.3 years, minimum = 1 year, maximum = 36 years). This demonstrated a statistically significant improvement in calibration as a function of increasing experience (P = .020). Longitudinal data were collected from 12 trainees at the start and end of their musculoskeletal radiology rotation, with an intervening review of the primary and secondary signs of ACL tear on MR. A statistically significant improvement in calibration was noted during the rotation (P = .028). CONCLUSIONS: Confidence calibration is a promising tool for quality improvement and radiologist self-assessment. Our study showed that calibration loss improves with experience in radiologists tested on a common and clinically important image classification task. We also demonstrated that calibration can be successfully taught to residents over a relatively short period (2-4 weeks).

Performance of an Interactive Upper Extremity Peripheral Nerve Training Module Among Medical Students, Radiology Residents, and Fellows: A Multi-institutional Study.

BACKGROUND AND PURPOSE: Chronic pain is a common problem and imaging is becoming increasingly utilized in the characterization of peripheral neuropathy, although this topic is not emphasized during medical training. We hypothesized that an electronic module and nerve atlas would be effective in improving comprehension among trainees. MATERIALS AND METHODS: In this IRB-approved study, a training module was created that included a side-by-side comparison of normal upper extremity nerves on magnetic resonance imaging and ultrasound (US), with embedded questions and cases, followed by a brief hands-on US scanning session. Thirty volunteers with variable training were enrolled in 1 institution, while 14 volunteers were enrolled in another. Pre- and post-test scores were collected and compared. RESULTS: There was a response rate of 100% at both institutions. At the first institution, subjects were divided into 2 groups: group 1 (16 medical students) and group 2 (14 residents/fellows). There was a baseline deficit of knowledge among both groups, with a mean pretest score of 37.5% and 47.5% for group 1 and group 2, respectively (P = 0.017). After module completion, both groups improved with a mean post-test score of 67.2% for group 1 and 76.1% for group 2. At the second institution, there was similar improvement even if the scanning session was not done. CONCLUSIONS: Use of an electronic module helps trainees to become more familiar with peripheral nerve imaging, regardless of level of training. Use of the module, even in the absence of hands-on US scanning, results in an improved understanding of this topic.

Pericytoma With t(7;12) and ACTB-GLI1 Fusion: Reevaluation of an Unusual Entity and its Relationship to the Spectrum of GLI1 Fusion-related Neoplasms.

The entity "pericytoma with t(7;12)" was described as a rare, distinct perivascular myoid neoplasm provisionally classified within the family of myopericytic tumors that demonstrates t(7;12)(p22;q13) translocation with resultant ACTB-GLI1 fusion and biologically was felt to behave in an indolent fashion. However, a recent study showed that tumors with this and similar translocations may have variable morphology and immunohistochemical phenotype with inconsistent myopericytic characteristics and a propensity for metastasis, raising questions regarding the most appropriate classification of these neoplasms. Herein, we report 3 additional patients with tumors harboring t(7;12) and ACTB-GLI1 fusion. The tumors arose in adults and involved the proximal tibia and adjacent soft tissues, scapula and adjacent soft tissues, and ovary. All tumors were composed of round-to-ovoid cells with a richly vascularized stroma with many small, delicate, branching blood vessels, where the neoplastic cells were frequently arranged in a perivascular distribution. Both tumors involving bone showed histologic features of malignancy. By immunohistochemistry, all tested tumors were at least focally positive for smooth muscle actin (3/3) and CD99 (patchy) (2/2), with variable staining for muscle-specific actin (2/3), S100 protein (1/3), epithelial membrane antigen (2/3), and pan-keratin (1/3); all were negative for desmin and WT1 (0/3). The 2 patients with bone tumors developed metastases (27 and 84 mo after diagnosis). Whether these tumors are best classified as malignant myopericytoma variants or an emerging translocation-associated sarcoma of uncertain differentiation remains to be fully clarified; however, our study further documents the potential for these tumors to behave in an aggressive fashion, sometimes over a prolonged clinical course.

Intraosseous Hibernoma: Five Cases and a Review of the Literature.

We present 5 cases of intraosseous hibernoma, a rare benign tumor of brown fat. Our literature review reveals that the average age at presentation is 58.6 years, and 69.7% of patients are female. Lesions are most often located in the spine and pelvis. Computed tomography usually demonstrates sclerotic changes, although lesions can be lytic. Magnetic resonance imaging findings include heterogeneous T2 hyperintensity. Technetium 99m-methyl diphosphonate bone scan reveals variable radiotracer uptake, whereas 18F-labeled fluoro-2-deoxyglucose (FDG) PET-CT shows mild uptake. Intraosseous hibernoma should be considered when imaging demonstrates a fat-containing lesion in bone, especially one exhibiting FDG avidity.