Primary leiomyosarcoma of bone: report of eight cases.

Eight primary leiomyosarcomas of bone were registered in the files of the Basel Bone Tumor Reference Center, Basel, Switzerland, for the period 1972 to 1990. The mean age of the patients (six males and two females) was 43.7 years (range, 11 to 87 years). The tumors were located in the long bones, the fingers, and the clavicle, and presented radiologically mainly as slightly to moderately aggressive lesions (grades IB to II according to Lodwick). They reacted immunohistochemically with antibodies against alpha-smooth muscle actin (alpha-SMA), and total muscle actins (eight of eight), vimentin (seven of eight), desmin (three of eight), keratin (four of eight), type IV collagen (six of eight), laminin (five of eight), and S-100 (one of eight). Seven patients underwent surgery (five, resection; two, amputation). Some of them had received preoperative or adjuvant chemotherapy or radiation therapy. One patient with a metastasized tumor had received chemotherapy only. Tumor recurrences were observed in two cases. Four patients developed metastases of whom two were treated with chemotherapy or tumor resection. During a follow-up period of 1 to 72 months (mean, 46.5 months) four of the eight patients survived for up to 72 months, among them the only patient with grade 3 tumor and treated metastases.

Diagnosis of tears in rotator-cuff-injuries.

Pathology of the rotator cuff is the cause of most common problems at the shoulder joint. Acute injuries are not as frequent as chronic cuff disease, but often they aggravate inflammatory or degenerative tendon alterations, even if they are of minor severity. Traumatic rotator cuff tears predominantly affect the supraspinatus tendon or the rotator interval. The subscapularis tendon is involved in anterior dislocations of the glenohumeral joint or in direct trauma. Plain film radiography still remains the base of all further imaging studies. If only full-thickness tears must be ruled out, double-contrast arthrography and ultrasound are acceptable imaging modalities. However, the former has a drawback in being invasive and does not detect partial tears at the bursal site of the cuff or rotator cuff tendinopathy, whereas the latter heavily depends on the experience of the radiologist and is restricted to the rotator cuff. Nowadays the most comprehensive imaging method is magnetic resonance (MR) imaging. MR imaging enables the detection or exclusion of complete rotator cuff tears with a reasonable accuracy and is also suitable to diagnose further pathologies of the shoulder joint. MR arthrography is valuable in the detection of subtle anatomic details and further improves the differentiation of rotator cuff diseases. Although in comparison MR imaging is still the most expensive imaging method, its high negative predictive value for the diagnosis of complete rotator cuff tears and its reliability evaluating different shoulder joint pathologies make it the preferred imaging modality.

Imaging the long head of biceps tendon--a pictorial essay emphasizing magnetic resonance.

Lesions of the long head of the bicepstendon (BT) are seen in association with tears of the rotator-cuff, particularly lesions of the subscapularis tendon and the rotator-interval. The frequency of positive MR-findings at the BT is approximately 25%. The pathologic alterations include complete medial luxation, subluxation and entrapment by the subscapularis tendon, tendinitis or tendovaginitis and lesions at the origin of the tendon at the superior labrum (superior labrum anterior to posterior (SLAP)--lesions). The imaging signs of BT pathology on MR include an abnormal course and position of the tendon, alterations in shape and changes in signal-intensity (SI), obliteration and thickening of the tendon-sheath. In long standing intra-articular BT rupture, neo-insertion of the tendon in the bicipital sulcus may ensue. The long BT needs to be visualized in transaxial, coronal oblique and sagittal oblique projections. Besides serving as stabilizer of the long head of biceps muscle, the BT is also an important stabilizer of the anterior joint capsule.

[Rare localizations of calcifying tendopathies]. / Seltene Lokalisationen verkalkender Tendopathien.

5 case-reports illustrate 2 rare locations of calcifying peritendinitis: The insertion of the deltoid tendon in the proximal humerus and the insertion of the gluteus maximus tendon in the femur. Knowledge of these insertion sites on one hand and the possibility of calcifying tendinitis at these sites on the other hand may allow proper diagnosis of certain shoulder- and hip joint pain syndromes and subsequent correct therapy.

[Efficiency of radiodiagnosis of acoustic neurinomas. Changes in the clarification procedure within the last 10 years]. / Effizienz der Radiodiagnostik von Akustikusneurinomen. Wandel des Abklärungsganges innerhalb der letzten 10 Jahre.

In a retrospective study we tried to define the diagnostic value of different x-ray studies in 43 histologically proved acoustic neuromas. We divided the examinations into such which definitely confirmed a clinical suspicion i.e. formed the last preoperative studies, and into others, which only increased the clinical suspicion. We were especially interested, whether or not Stenvers and transorbital projections of the petrous bones and internal acoustic canals and petrous bone tomographies were essentially confirming clinical diagnosis. Whereas 13 out of 37 Stenvers, 2 out of 5 transorbital projections and 14 out of 18 frontal tomographies increased the suspicion of an existing Neuroma, a true diagnostic confirmation was never possible with these 3 techniques. Vice versa out of 45 computertomographies 33 were confirming the clinical diagnosis and 1 increased the clinical suspicion, with 5 false negatives and 6 nonconclusive studies. CT and Air-CT-Cisternography represent today the definitive diagnostic studies. For economical reasons they should be employed early in the diagnostic course, in those cases with high clinical suspicion or when clinical symptoms suggesting AN persist.

[The radiological findings in adamantinoma of the long tubular bones]. / Radiologische Befunde beim Adamantinom der langen Röhrenknochen.

The radiological findings of adamantinomas of long bones are described in 22 patients. The diagnosis was confirmed by a team of experts (pathologist, radiologist, orthopaedic surgeon) of the "Bone tumour study group" at the German Cancer Research Center. There were 12 male and 10 female patients aged 5 to 67 years (most commonly in the second and third decade). In 21 patients the tibia was involved and in one patient the fibula. The tumour was nearly always in the diaphysis (20 cases). The most striking radiological feature was a diaphyseal lesion confined to the bone showing multicentric translucencies. The latter showed surrounding or central ring shaped or focal areas of increased density. The lesions tended to be longitudinal, averaging 11 cm (between 3 and 25 cm). All lesions showed a sclerotic margin separating it from normal bone, at least over part of the lesion. Expanding lesions were mostly separated from the soft tissues by a bony rim (18 cases).

Tumours and tumour-like lesions of scapula.

A retrospective study of 68 cases of tumours and tumour-like lesions related to the scapula, included in the registry of the Bone Tumour Reference Centre at the Institute of Pathology/University Clinics, Basle, has been carried out. Each case was evaluated for lesion entity, activity and location, age and sex of the patient, and, in 49 files with available radiographic documentation (mostly plain films), for radiologic appearance, with the aim to predict the histologic diagnosis or at least the correct dignity of the lesion. Statistically most frequent were cartilaginous tumours. More than 1/3 of all cases were osteochondromas, which demonstrated mostly a typical appearance. They were encountered predominantly in the first 3 decades in males and were located most often in the body of the scapula. 1/4 of all cases were chondrosarcomas, which were prevailing in the 4th-7th decades, but were occasionally found at a younger age too. Chondrosarcomas were located mainly at the lateral scapular margin over the inferior angle and in the acromion and coracoid process and their appearance ranged from typical to falsely benign. 1/3 of the cases represented a number of other benign and malignant histological entities.

Comparison of carotid plaque ulcer detection using contrast-enhanced and time-of-flight MRA techniques.

BACKGROUND AND PURPOSE: Ulceration in carotid plaque is a risk indicator for ischemic stroke. Our aim was to compare plaque ulcer detection by standard TOF and CE-MRA techniques and to identify factors that influence its detection. MATERIALS AND METHODS: Carotid MR imaging scans were acquired on 2066 participants in the ARIC study. We studied the 600 thickest plaques. TOF-MRA, CE-MRA, and black-blood MR images were analyzed together to define ulcer presence (plaque surface niche ≥2 mm in depth). Sixty ulcerated arteries were detected. These arteries were randomly assigned, along with 40 nonulcerated plaques from the remaining 540, for evaluation of ulcer presence by 2 neuroradiologists. Associations between ulcer detection and ulcer characteristics, including orientation, location, and size, were determined and explored by CFD modeling. RESULTS: One CE-MRA and 3 TOF-MRAs were noninterpretable and excluded. Of 71 ulcers in 56 arteries, readers detected an average of 39 (55%) on both TOF-MRA and CE-MRA, 26.5 (37.5%) only on CE-MRA, and 1 (1.5%) only on TOF-MRA, missing 4.5 (6%) ulcers by both methods. Ulcer detection by TOF-MRA was associated with its orientation (distally pointing versus perpendicular: OR = 5.57 [95% CI, 1.08-28.65]; proximally pointing versus perpendicular: OR = 0.21 [95% CI, 0.14-0.29]); location relative to point of maximum stenosis (distal versus isolevel: OR = 5.17 [95% CI, 2.10-12.70]); and neck-to-depth ratio (OR = 1.96 [95% CI, 1.11-3.45]) after controlling for stenosis and ulcer volume. CONCLUSIONS: CE-MRA detects more ulcers than TOF-MRA in carotid plaques. Missed ulcers on TOF-MRA are influenced by ulcer orientation, location relative to point of maximum stenosis, and neck-to-depth ratio.

Maintenance of certification: update on attitudes of members of the American Society of Neuroradiology.

BACKGROUND AND PURPOSE: Neuroradiology is in the fifth year of subspecialty recertification. New requirements for the MOC process include a PQI initiative. The purpose of this report was to survey compliance of ASNR members with the MOC process. MATERIALS AND METHODS: A 12-question Internet-based survey was sent to the 2864 members of the ASNR through e-mail addresses. The survey asked questions regarding compliance with cognitive testing, SAMs, CME credits, and PQI. Multiple reminders were sent and open comments graded for attitudes toward the MOC process. RESULTS: While most respondents were engaged in the MOC process (878/1074 [81.8%]) and were aware of CME and SAMs, (736/1067 [69%]) and cognitive testing requirements of the recertification, the PQI initiative had limited participation and many questions about the component. Of the 1057 respondents, 687 (490 not started, 87 registered but not started, 110 unaware of PQI) or 65% had not started a PQI project at the time of the survey. The ASNR was asked to help with the cognitive examination by 25 (4.4%), CME offerings by 53 (9.4%), SAM modules by 88 (14.0%), and PQI projects by 205 (36.2%) respondents. Open comments were generally unfavorable toward the MOC-PQI process by a 3:1 ratio. CONCLUSIONS: Compliance with the MOC process has improved since a prior survey 3 years ago; however, confusion over the PQI process remains the primary concern of ASNR members.

[Imaging methods in breast diagnosis--value and choice of methods in general practice]. / Bildgebende Methoden bei der Mammadiagnostik--Aussagekraft und Methodenwahl in der Praxis.

X-ray mammography continues to represent the most efficient imaging method for the diagnosis of breast disease and ultimately reduce mortality from breast cancer. Ultrasound is the most valuable supplementary method and is particularly useful to differentiate cystic from solid lesions. Today it is used mostly in the dense breast, as e.g. in young patients. All other imaging methods as thermography, diaphanoscopy, computed tomography and magnetic resonance imaging have not gained any importance and are particularly not useful for screening a large number of patients. In this paper all these imaging methods and our personal experience with them are briefly discussed. The importance of implementing mammographic screening programs to detect breast cancer is stressed, particularly considering the high incidence of breast cancer in all industrialized countries.

[Imaging diagnosis in femur head necrosis with emphasis on skeletal scintigraphy and magnetic resonance tomography]. / Bildgebende Diagnostik bei der Femurkopfnekrose mit Betonung der Skelettszintigraphie und Magnetresonanztomographie (MRT/MRI).

Early diagnosis and treatment of avascular necrosis (AVN) of the femoral heads improve the prognosis of this disorder. Of the different radiological studies available so far, none has been truly satisfactory. Conventional X-rays frequently show alterations in the femoral heads only in later stages. Early on these may be so subtle that they are overlooked by the examiner. Bone scintigraphy is more sensitive than conventional X-rays in the detection of early alterations, but there are still up to 18% negative studies in biopsy-proven femoral-head necrosis. The sensitivity of this method is also diminished when bilateral AVN is present. This is frequently the case even if only one hip joint is symptomatic. Computed tomography (CT) and single photon emission computed tomography (SPECT) are highly sensitive methods that are still not widely used for the diagnosis of AVN. With SPECT, clinical experience is still limited. A number of publications in recent years have revealed the excellent characteristics of magnetic resonance imaging (MRI) in showing the pathological processes in bone marrow and, in particular, AVN. This paper summarizes a few of these publications and our personal experience with MRI in AVN of the femoral head. Different cases examples are given.

The rope ladder: an uncommon artifact and potential pitfall in MR arthrography of the shoulder.

OBJECTIVE: MR arthrograms were retrospectively reviewed for susceptibility artifacts induced by accidental injection of a small amount of gas when paramagnetic contrast solution was injected. A pitfall to interpretation, an unusual distribution of intraarticular gas into the sheath of the long biceps tendon that resembled a rope ladder, was observed and compared with findings of bicipital tenosynovitis. CONCLUSION: Intraarticular gas contamination during MR arthrography must be differentiated from intraarticular loose bodies and findings of bicipital tenosynovitis. Most reliable for the differential diagnosis are the different shapes and sizes of the gas-induced susceptibility artifacts on spin-echo and gradient-recalled echo images.

MR arthrographic findings in tenosynovitis of the long bicipital tendon of the shoulder.

PURPOSE: To assess the MR arthrographic findings of bicipital tenosynovitis in correlation with arthroscopy. DESIGN AND PATIENTS: The shoulder MR arthrographies of 500 consecutive patients were retrospectively analyzed for signs of bicipital tenosynovitis and associated pathologies. Forty patients (8%) had MR evidence of bicipital tenosynovitis, but only 17 (3%) with arthroscopic confirmation were included in the study. The MR findings in these patients were compared with those of 10 patients with rotator cuff lesions but arthroscopically normal long biceps tendons. MR arthrography was performed with 10-15 ml of a 250 mmol/l gadoterate meglumine (Gd-DOTA) solution injected under fluoroscopic guidance, and transaxial, oblique coronal and sagittal MR sequences were obtained. RESULTS: All 17 patients showed one or more abnormal findings: signal increase in the tendon with or without fusiform distension was seen in 12, surface irregularities in six, adhesions in 11 and noncommunicating effusions of the tendon sheath in six. Associated abnormalities of the rotator cuff were present in 16 while the seventeenth patient had glenohumeral synovitis without rotator cuff pathology. MR arthrograms correlated with arthroscopic findings in the joint but comparison was not possible in the intertubercular groove portion of the biceps tendon. None of the 10 patients with an arthroscopically normal biceps tendon showed any of the MR findings of bicipital tenosynovitis. CONCLUSION: Bicipital tenosynovitis is detectable by MR arthrography. In most cases it is an associated finding of rotator cuff abnormalities and likely to have a similar etiology. When lesions of the anterior rotator cuff are recognized, the biceps tendon should be scrutinized for inflammatory changes.

[Pain following operations of the lumbar spine. The "failed back surgery syndrome"]. / Schmerzen nach Operationen an der Lendenwirbelsäule. Das 'Failed Back Surgery Syndrome' (FBSS).

This is a follow up study of 61 patients with a 'failed back surgery syndrome' (FBSS). The mean follow up time is 5.4 years after the first operation on the lumbar spine. The diagnosis before the first operation was in 35 patients an entrapment disease (disc herniation or stenosis of the spinal canal), in 25 patients a segmental instability and once a deformity. The reason for the development of a 'failed back surgery syndrome' was in 18% a perioperative complication, in 24% a late unhappy consequence of the operation, in 40% an assessment- or treatment error. In 18% we were not able to figure out any reason for the failure. The correlating diagnosis were: postoperative infections 3, hematoma 1, disc herniation or instability on a second level 12, a second disc herniation at the same level 3, scarring or arachnoiditis 2, instability 18, lateral spinal stenosis 10. We emphasize the importance to distinguish between a clinical relevant and irrelevant diagnosis and to use special tests for this differentiation.

Peritoneal calcification in a neonate with imperforate hymen.

Contrast medium for vaginography in a premature neonate passed into the peritoneal cavity; calcification in that area apparently represented genital-tract secretions which had accumulated above the imperforate hymen. Ultrasonography of the mother's abdomen had indicated fetal ascites, a finding that may be of value in diagnosing genital-tract obstruction prenatally.

Conglomerate pulmonary disease: a form of talcosis in intravenous methadone abusers.

A program of detoxification of heroin addicts by the use of oral methadone produced a series of patients who developed pulmonary granulomatous mass lesions as the result of the intravenous use of the oral form of the drug. Talc, used in the preparation of the tablet, seems to be the offending substance. Besides producing a diffuse interstitial granulomatous reaction, conglomerate masses in the upper lung zones were also noted. This radiographic pattern can occur rather rapidly from the background of fine diffuse interstitial micronodularity. The latter may be subtle, but can change to mass lesions associated with lung contraction, volume loss in the upper lung zones, and hyperinflation in the lower lungs. The mechanism of formation of mass lesions is unknown, but individual host reaction and immunologic mechanisms probably play a role. The development and progress of such a process is described in four heroin addicts.