Search

The radiographic appearance of primary bone tumors is important for initial diagnosis and often augments histopathological analysis. The original grading system relied on the radiographic analysis of the margin of the lesions to determine tumor aggression, which often corresponds with malignant potential. The recently developed, modified Lodwick-Madewell grading system also incorporates the appearance of lesion margins on radiographs but also considers the change in margins on serial radiographs and includes a category for clinically suspected, radiographically occult, aggressive lesions. This article reviews the prior and modified grading systems, and the concepts necessary for proper interpretation of the initial appearance of bone tumors which often determines the radiologist's recommendation for biopsy or follow-up imaging.

Functional imaging can add valuable information to conventional imaging in the settings of tumor characterization and treatment response assessment. Traditional response criteria rely primarily on physical measurements, while functional imaging can potentially give a more comprehensive evaluation of oncological status. The second part of this review article discusses advanced imaging techniques such as susceptibility-weighted imaging, tumor-associated macrophage imaging, diffusion-weighted imaging, perfusion-weighted imaging, Dixon imaging, whole-body magnetic resonance imaging, whole-body low-dose dual energy computed tomography with virtual noncalcium technique, and ultrasound elastography.

MRI-guided laser interstitial thermal therapy (LITT) is the selective ablation of a lesion or a tissue using heat emitted from a laser device. LITT is considered a less invasive technique compared to open surgery that provides a nonsurgical solution for patients who cannot tolerate surgery. Although laser ablation has been used to treat brain lesions for decades, recent advances in MRI have improved lesion targeting and enabled real-time accurate monitoring of the thermal ablation process. These advances have led to a plethora of research involving the technique, safety, and potential applications of LITT. LITT is a minimally invasive treatment modality that shows promising results and is associated with decreased morbidity. It has various applications, such as treatment of glioma, brain metastases, radiation necrosis, and epilepsy. It can provide a safer alternative treatment option for patients in whom the lesion is not accessible by surgery, who are not surgical candidates, or in whom other standard treatment options have failed. Our aim is to review the current literature on LITT and provide a descriptive review of the technique, imaging findings, and clinical applications for neurosurgery.

The lumbar artery perforator (LAP) flap is a relatively new procedure that can be utilized to manage lumbosacral defects in addition to reconstructing distal body parts as well, such as breast reconstruction. This fasciocutaneous flap is designed based on the LAPs small arteries that emerge from the lumbar arteries then move superficially piercing overlying tissues to perforate the lumbar fascia and supply the skin and subcutaneous tissue; However, anatomical and clinical studies regarding the LAP flap and its perforators are sparse in the literature, and the results are even contradicting. This article will discuss the LAP flap, the anatomy of its perforators, and the clinical aspects about its usage. In addition, we explore its preoperative imaging evaluation, and deliver a guide on image reporting and radiological data that will benefit the surgeon most during the procedure.

Background Heterotopic Ossification (HO) is a common condition referring to ectopic bone formation in soft tissues. It has two major etiologies, acquired (more common) and genetic. The acquired form is closely related to tissue trauma. The exact pathogenesis of this disease remains unclear; however, there is ongoing research in prophylactic and therapeutic treatments that is promising. Conclusions Due to HO potential to cause disability, it is so important to differentiate it from other causes in order to establish the best possible management.

Multiple myeloma is a common hematologic malignancy of plasma cells. Differentiating multiple myeloma from the precursor stages of monoclonal gammopathy of undetermined significance and smoldering multiple myeloma is very important because the treatment approach is different for each. The diagnosis is mainly clinical, while the role of imaging is confined to the staging process, assessing response to therapy, and monitoring for disease progression. In this article, we examine the role of different imaging modalities in patients with multiple myeloma.

The mechanisms by which tumors metastasize to bone are complex. Upon the successful establishment of metastatic deposits in the skeleton, detection of the disease becomes essential for therapeutic planning. The roles of CT, skeletal scintigraphy, SPECT/CT, MRI, PET/CT and PET/MRI will be reviewed. Therapeutic response criteria specifically designed to evaluate bone metastases (MD Anderson/MDA criteria) can guide image interpretation. Knowledge of therapeutic strategies such as systemic therapy with bisphosphonates or radiopharmaceuticals, radiation therapy, surgery, and percutaneous interventions such as vertebroplasty and radiofrequency ablation can help the radiologist produce reports that will provide maximum benefit to clinicians and patients.

The responsible use of gadolinium-based contrast agents (GBCAs) requires a balance between safety and clinical utility. While nephrogenic systemic fibrosis (NSF) has been associated with most linear GBCAs few, if any, new cases have been verified since the successful implementation of screening programs to detect renal impairment and prevent susceptible patients from receiving these higher-risk agents. The likelihood of developing nephrogenic systemic fibrosis has been shown to be negligible with macrocyclic agents, prompting the American College of Radiology and other regulatory agencies to suggest that no screening is necessary when they are used. There is no solid evidence of negative clinical effect from the retention of macrocyclic agents in the brain while there is evidence that they wash out of the brain over time. GBCAs have many important clinical uses that can help prevent morbidity or death. This article reviews the risks and benefits of GBCA administration.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in [Seminars in Ultrasound, CT, and MRI, 41/2 (2020) 170–182], https://dx.doi.org/10.1053/j.sult.2019.12.005. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal

Dermatofibrosarcoma protuberans (DFSP) is a rare, low-to-intermediate grade sarcoma that typically arises in the dermis and infiltrates subcutaneous tissue. Due to superficial appearance of DFSP, imaging techniques are not always utilized. However, they may be useful in large or atypical cases. The standard treatment for DFSP is excision of the lesion. In this article, we review the role of different imaging modalities in the assessment and management of DFSP.

Glomus tumors are hamartomas, which tend to occur in sites rich in glomus bodies, such as the subungual regions of digits or the deep dermis of the palm, wrist, forearm, and foot. Very rarely, they may involve peripheral nerves. We describe a patient, who, following surgical resection of a solitary glomus tumor of the left distal sciatic nerve in his teens, had recurrence with development of multiple tumors in the course of the nerve over several years. To our knowledge, this is the only known case of glomangiomatosis involving a major peripheral nerve.

Liposarcoma is a commonly occurring soft tissue sarcoma that can be divided into 4 subtypes. Myxoid and round cell liposarcoma (MRCL) represent one of these subtypes and are classified together due to their shared chromosomal translocation. Histologic analysis of MRCL reveals a myxoid matrix with a delicate capillary network and dispersed lipoblasts. Varying degrees of round cell component are also observed, with greater amounts of round cells indicating a higher histologic grade and poorer prognosis. MRCL has a unique pattern of spread due to its initial tendency to spread to extrapulmonary sites. Additionally, skeletal metastases are frequently found in cases of MRCL. While various imaging techniques are used to visualize MRCL and metastases, magnetic resonance imaging is generally the preferred method. This article reviews the pathophysiology and imaging features of MRCL as well as the imaging characteristics, advantages, and drawbacks of multiple imaging modalities for visualizing bone metastases.

PURPOSE To develop a flexible fast spin echo (FSE) triple-echo Dixon (FTED) technique. METHODS An FSE pulse sequence was modified by replacing each readout gradient with three fast-switching bipolar readout gradients with minimal interecho dead time. The corresponding three echoes were used to generate three raw images with relative phase shifts of -θ, 0, and θ between water and fat signals. A region growing-based two-point Dixon phase correction algorithm was used to joint process two separate pairs of the three raw images, yielding a final set of water-only and fat-only images. The flexible FTED technique was implemented on 1.5T and 3.0T scanners and evaluated in five subjects for fat-suppressed T2-weighted imaging and in one subject for post-contrast fat-suppressed T1-weighted imaging. RESULTS The flexible FTED technique achieved a high data acquisition efficiency, comparable to that of FSE, and was flexible in scan protocols. The joint two-point Dixon phase correction algorithm helped to ensure consistency in the processing of the two separate pairs of raw images. Reliable and uniform separation of water and fat was achieved in all of the test cases. CONCLUSION The flexible FTED technique incorporates the benefits of both FSE and Dixon imaging and provided more flexibility than the original FTED in applications such as fat-suppressed T2-weighted and T1-weighted imaging. Magn Reson Med 77:1049-1057, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Extraskeletal osteosarcoma are rare malignant mesenchymal neoplasms of soft tissues representing around 1% of all soft tissue. The exact mechanism of tumorigenesis of primary breast osteosarcoma is still unclear. However, most of the cases develop without a recognized etiologic factor. Primary osteosarcoma of the breast is often initially misdiagnosed as breast fibroadenoma. Different imaging modalities and pathology play important role in differentiating breast osteosarcoma from other benign and malignant lesions of the breast resulting in dramatic change in the management.

Granulocyte colony-stimulating factor (G-CSF) analogs such as filgrastim/pegfilgrastim are increasingly used to enhance neutrophilic recovery after chemotherapy. It is widely known that, physiologically, pegfilgrastim stimulates marrow mitotic activity and induces marrow reconversion from fatty to cellular. However, there is limited literature discussing the effects of pegfilgrastim on musculoskeletal magnetic resonance imaging, with the consensus that marrow reconversion secondary to pegfilgrastim therapy is easily confounded with a malignant process, especially in patients with a history of cancer. We attempt to discuss the expected changes and MRI findings after pegfilgrastim therapy through a summary of current literature. Additionally, we provide images from our own practice to support the previously established findings. G-CSF-stimulated reconversion can appear as patchy expansions of baseline hematopoietic marrow, but can also appear to be diffusely homogeneous, adding to its ambiguity. We conclude that using a baseline MRI, clinical information, and assessing sequential MRI changes in conjunction with pegfilgrastim therapy may aid the differentiation between benign and pathological change. We expand our discussion to include the effects of novel technologies, such as whole-body MRI, chemical shift imaging, and contrast agents in helping the distinction.

Lipomas are benign tumors consisting primarily of mature adipocytes. Imaging is important in distinguishing benign ossifying lipoma from more aggressive tumors such as well-differentiated liposarcomas. Early diagnosis of ossifying lipoma and understanding of its benign etiology prevent unwarranted medical intervention such as biopsies and surgical resection, as well as decrease patient anxiety.

OBJECTIVE. The objective of this video article is to discuss the use of the scapular osteocutaneous free flap in reconstructive procedures. We attempt to discuss normal and variant vascular anatomy, image acquisition via CT angiography, and image interpretation as well as computer-assisted design and manufacturing. CONCLUSION. The scapular osteocutaneous free flap is commonly used for maxillary and mandibular reconstructive surgery. The complex vasculature supplying the scapular region allows flap versatility. There are anatomic variations in the origin of the circumflex scapular and angular arteries. Our method of performing and reporting CT angiography for patients scheduled to undergo scapular osteocutaneous free flap procedures provides a reliable and reproducible means of communicating important elements of vasculature to surgeons. This in turn can facilitate the manufacturing of custom scapular cutting guides and improve surgical outcomes.

Enchondromas are common benign bone lesions that are found in the medullary cavity of tubular bones, usually at the metaphysis. Regression is highly unusual, and loss of matrix mineralization in an existing enchondroma should prompt investigation for malignant transformation. We present the case of a 50-year-old woman with an enchondroma of the proximal humeral metadiaphysis, which underwent loss of matrix mineralization that corresponded to replacement with marrow fat on MRI. This transformation of the cartilage tumor matrix into normal bone marrow may occur in a process similar to that seen with endochondral ossification.

The purpose of the study was to evaluate the conspicuity of bone metastases on each of the numerous sequences produced by fast Dixon-based multisequence whole-body (WB) magnetic resonance imaging (MRI) scanning in order to determine the most clinically useful sequences overall and per anatomic region.Twenty-seven breast cancer patients with bone metastases were prospectively studied with fast Dixon-based WB MRI including head/neck, chest, abdominal, pelvic, thigh, calf/feet and either cervical, thoracic and lumbar or cervical/thoracic and thoracic/lumbar regions. Sequences included coronal T2, axial T1 without and with intravenous gadolinium (+C), sagittal T1 spine+C, each associated fat-only (FO) and fat-saturated (FS) sequence, axial diffusion-weighted imaging (DWI) and short tau inversion recovery (STIR). Blinded reviewers evaluated lesion conspicuity, a surrogate of clinical utility, on a five-point scale per anatomic region. Sequences were compared using analysis of variance, differences were detected with Tukey's honestly significant difference test, and the four sequences with highest mean conspicuity were compared to the remainder overall and per anatomic region.Overall, a significant lesion conspicuity difference was found (P.0001), and lesion conspicuity was significantly higher on FS T1+C, FO T1+C, T1+C sagittal and FS T1+C axial sequences (P.0001). Per-region results were the same in the head/neck. Other sequences overlapped with these and included the following: chest/abdomen - FO T2, DWI; pelvis - DWI, FO T2; thigh - FS T2, FO T2, FO T1+C; calf/feet - FS T2, DWI, FO T2, STIR.Overall, bone lesions were most conspicuous on FS T1+C sagittal, FO T1+C sagittal, T1+C sagittal and FS T1+C axial fast Dixon WB MRI sequences.

We present a rare osteochondroma, which instead of being the usual exophytic growth outside bone, grew inward into the medullary cavity of distal femur in a patient with prior trauma to his knee. Except for its intramedullary location, the benign tumor had all the classic radiographic and pathologic features of typical osteochondroma.

OBJECTIVE. This video article will review the relevant vascular anatomy of the anterolateral thigh flap, describe the CT angiography (CTA) image acquisition, and describe how to report the locations of the perforating arteries along with characteristics that may be important to the surgeon. CONCLUSION. Our method of performing and reporting CTA for patients scheduled to undergo anterolateral thigh flap reconstruction provides a reproducible method of identifying perforating vessels and communicating their location to surgeons.

Background: The tendency of myxofibrosarcoma (MFS) to have a non-nodular appearance on magnetic resonance imaging (MRI) may present a challenge in detection of local recurrence. Appropriate index of suspicion of expected imaging appearance can alleviate this challenge. Objectives: Our objectives were to determine if: 1) imaging pattern at recurrence is associated with delayed diagnosis, and 2) appearance at recurrence can be predicted based on appearance at presentation. Patients and Methods: A retrospective cohort study was performed. Two analysis groups were used: patients with recurrence captured on MRI (objective 1) and patients with MRI prior to resection and at recurrence (objective 2). Three radiologists scored images independently and in consensus as infiltrative (tail-like spread), focal (absence of spread), or mixed. Consensus results were used for analysis with Fisher’s exact test. Results: There was substantial agreement among the 3 readers (k = 0.72, 95% confidence interval: 0.59 - 0.85). Half of all infiltrative cases were associated with a delay in diagnosis, compared to 10% of mixed or focal cases; however, there was no statistically significant association between infiltrative pattern at recurrence and delayed diagnosis (P = 0.08). In 70% of cases, recurrence had the same appearance as presentation, suggesting a trend; however, there was no association between appearance at baseline and recurrence (P = 0.1). Conclusion: Imaging appearance at baseline does not reliably predict imaging appearance at recurrence. Therefore, a high index of suspicion for the infiltrative pattern is required in assessment of post-operative MRIs in patients with MFS.

A literature review was performed of studies reporting sensitivity and specificity of [18F]fluorodeoxyglucose (FDG) PET from January 1, 2000 to January 1, 2010. PET was found to have higher sensitivity for the detection of osseous metastases when compared to CT, skeletal scintigraphy, whole body MRI and combined conventional imaging modalities. A potential exception is when comparing PET with bone scan in the setting of blastic metastases. PET may be a better indicator of active bony metastases. The efficacy of PET can be increased with fused anatomic imaging.

An enchondroma with complex cystic changes of the proximal femur is described in a 13-year-old male. The case illustrates a unique presentation of an enchondroma and reinforces the importance of considering the presence of secondary aneurysmal bone cysts in both benign and malignant lesions of bone.

Our purposes were to explore the epidemiology of metastases to skeletal muscle and their detection on fused positron emission tomography and computed tomography.We evaluated the epidemiology of skeletal muscle metastases in the literature and among cases from our hospital and studied the prevalence and appearance of skeletal muscle metastases among 433 patients undergoing fused positron emission tomography and computed tomography for non-small-cell lung cancer.We found 264 cases of skeletal muscle metastases in 151 articles. Mean age was 57.8 years with 67% men. At our hospital we studied 70 cases. Mean patient age was 55.7 years with 63% men. The most common source was lung cancer, and the most common site of involvement was the muscles of the trunk. Among our lung cancer patients undergoing fused positron emission tomography and computed tomography, we found 7 (1.6%) with skeletal muscle metastases. In only one of these seven patients was the metastasis first discovered by another imaging modality. In one patient discovery of the metastasis at fused positron emission tomography and computed tomography changed management.Skeletal muscle metastases are not rare. They may be more apparent at fused positron emission tomography and computed tomography than at other staging examinations, particularly contrast-enhanced CT scanning. Radiologists need to be alert to their presence when interpreting staging examinations in cancer patients.

To evaluate the feasibility of fast Dixon whole-body (WB) magnetic resonance imaging (MRI) for detecting bone and liver metastasis in clinical patients and to compare its performance with skeletal scintigraphy (SS) for detecting bone metastases using reference imaging with1 year follow-up as the gold standard.Twenty-nine patients with bone metastases prospectively underwent WB MRI and SS. WB MRI included coronal T2, axial T1 with and without intravenous gadolinium (including triphasic liver sequences), and axial diffusion-weighted imaging, plus spinal sagittal postcontrast T1-weighted images. The skeleton was divided into 16 segments. Reviewers blinded to other images identified up to five lesions per segment and rated them using a five-point confidence scale for metastatic disease. Sensitivities and specificities were compared using the McNemar test.The sensitivity of WB MRI and SS in detecting bone metastases was 70.8% and 59.6% (P = 0.003), respectively; specificity was 89.1% and 98.7% (P0.0001). WB MRI detected all livers with metastases (n = 8). One focal nodular hyperplasia was classified as a metastasis on WB MRI.Fast Dixon WB MRI is feasible in clinical patients, highly specific, and more sensitive than SS in detecting bone metastases, and can detect metastases of the liver.

Primary sarcomas of the thorax are uncommon. The purpose of this review is to describe the radiologic findings of sarcomas affecting the thorax, in particular the chest wall, pleura, and lungs. Most primary sarcomas affecting the thorax arise in the chest wall, and the most common sarcomas of the chest wall are chondrosarcoma, osteosarcoma, Ewing's sarcoma/primitive neuroectodermal tumor, malignant fibrous histiocytoma, and fibrosarcoma. Primary pleural and pulmonary sarcomas are rare. Although histologic analysis is almost always required for accurate diagnosis, imaging is important for staging of these tumors, and several of these tumors have distinctive radiologic features, allowing the radiologist to narrow the differential diagnosis.

Inversion recovery has been used to correct the loss of CSF and tissue contrast at 3 T versus 1.5 T but has not been formally investigated in the spine after IV administration of gadolinium-based contrast agent. The purpose of this study is to compare two sequences for gadolinium-enhanced spine imaging at 3 T--fat-saturated T1-weighted FLAIR and fat-saturated T1-weighted fast spin-echo (FSE)--for evaluation of extradural lesions and CSF-cord contrast.After IV administration of gadolinium-based contrast agent, fat-saturated T1-weighted FSE and FLAIR sequences were obtained in 156 MRI scans of 143 patients at 3 T. Three experienced radiologists compared these sequences for conspicuity differences in bone lesions, disk lesions, other epidural lesions, and cord-CSF contrast. A 7-point visual rating scale was used, with lower numbers indicating increased conspicuity on gadolinium-enhanced fat-saturated T1-weighted FLAIR and higher numbers indicating increased conspicuity on gadolinium-enhanced fat-saturated T1-weighted FSE.A slight increase in the conspicuity of gadolinium-enhancing bone lesions (mean score, 3.6; p0.0001), disk lesions (mean score, 3.5; p0.0001), and epidural lesions (mean score, 3.4; p0.0001) was seen on fat-saturated T1-weighted FLAIR compared with fat-saturated T1-weighted FSE. A higher degree of contrast between the spinal cord and CSF was seen on fat-saturated T1-weighted FLAIR, by a large margin (mean score, 1.8; p0.0001). All enhancing lesions seen on fat-saturated T1-weighted FSE images were also seen on fat-saturated T1-weighted FLAIR images.Decreased CSF-cord contrast at 3 T, as seen on T1-weighted FSE, can be regained by using T1-weighted FLAIR. Fat-saturated T1-weighted FLAIR may increase conspicuity of gadolinium-enhancing extradural lesions compared with fat-saturated T1-weighted FSE.

Parachordoma is a rare tumor, with fewer than 100 cases reported. We present an unusual presentation of a long tumor tracking along the median nerve, with regional metastasis to the axillary nodes in a 67-year-old woman. The tumor extended from the wrist proximally along the forearm to the elbow, coursing intraneurally along the median nerve. We present this case due its rarity, interesting radiographic appearance, and atypical presentation.

The National Lung Screening Trial (NLST) is a randomized multicenter study comparing low-dose helical computed tomography (CT) with chest radiography in the screening of older current and former heavy smokers for early detection of lung cancer, which is the leading cause of cancer-related death in the United States. Five-year survival rates approach 70% with surgical resection of stage IA disease; however, more than 75% of individuals have incurable locally advanced or metastatic disease, the latter having a 5-year survival of less than 5%. It is plausible that treatment should be more effective and the likelihood of death decreased if asymptomatic lung cancer is detected through screening early enough in its preclinical phase. For these reasons, there is intense interest and intuitive appeal in lung cancer screening with low-dose CT. The use of survival as the determinant of screening effectiveness is, however, confounded by the well-described biases of lead time, length, and overdiagnosis. Despite previous attempts, no test has been shown to reduce lung cancer mortality, an endpoint that circumvents screening biases and provides a definitive measure of benefit when assessed in a randomized controlled trial that enables comparison of mortality rates between screened individuals and a control group that does not undergo the screening intervention of interest. The NLST is such a trial. The rationale for and design of the NLST are presented.

The aim of our study was to retrospectively evaluate whether maximum standardized uptake value (SUVmax), total lesion gylcolysis (TLG), or change therein using 18F-FDG PET/CT performed before and after initial chemotherapy were indicators of patient outcome. Methods: Thirty-one consecutive patients who underwent 18F-FDG PET/CT before and after chemotherapy, followed by tumor resection, were retrospectively reviewed. Univariate Cox regression was used to analyze for relationships between covariates of interest (SUVmax before and after chemotherapy, change in SUVmax, TLG before and after chemotherapy, change in TLG, and tumor necrosis) and progression-free and overall survival. Logistic regression was used to evaluate tumor necrosis. Results: High SUVmax before and after chemotherapy (P = 0.008 and P = 0.009, respectively) was associated with worse progression-free survival. The cut point for SUVmax before chemotherapy was greater than 15 g/mL* (P = 0.015), and after chemotherapy it was greater than 5 g/mL* (P = 0.006), as measured at our institution and using lean body mass. Increase in TLG after chemotherapy was associated with worse progression-free survival (P = 0.016). High SUVmax after chemotherapy was associated with poor overall survival (P = 0.035). The cut point was above the median of 3.3 g/mL* (P = 0.043). High TLG before chemotherapy was associated with poor overall survival (P = 0.021). Good overall and progression-free survival was associated with a tumor necrosis greater than 90% (P = 0.018 and 0.08, respectively). A tumor necrosis greater than 90% was most strongly associated with a decrease in SUVmax (P = 0.015). Conclusion:18F-FDG PET/CT can be used as a prognostic indicator for progression-free survival, overall survival, and tumor necrosis in osteosarcoma.

Positron emission tomography (PET)-computed tomography (CT) is a useful device in identifying musculoskeletal lesions that require biopsy. It can be used to localize the primary lesion, identify a site to biopsy, and evaluate metastatic lesions that require follow-up biopsies. Not all malignant tumors have hypermetabolic activity, and there are many benign lesions and physiologic processes that do have increased F-18 fluorodeoxyglucose uptake. Knowledge of these issues is important when reviewing PET-CT and directing subsequent musculoskeletal biopsies.

BACKGROUND AND PURPOSE: Osseous pseudoprogression on MR imaging can mimic true progression in lesions treated with spine stereotactic radiosurgery. Our aim was to describe the prevalence and time course of osseous pseudoprogression to assist radiologists in the assessment of patients after spine stereotactic radiosurgery. MATERIALS AND METHODS: A secondary analysis of 2 prospective trials was performed. MRIs before and after spine stereotactic radiosurgery were assessed for response. “Osseous pseudoprogression” was defined as transient growth in signal abnormality centered at the lesion with a sustained decline on follow-up MR imaging that was not attributable to chemotherapy. RESULTS: From the initial set of 223 patients, 37 lesions in 36 patients met the inclusion criteria and were selected for secondary analysis. Five of the 37 lesions (14%) demonstrated osseous pseudoprogression, and 9 demonstrated progressive disease. There was a significant association between single-fraction therapy and the development of osseous pseudoprogression ( P = .01), and there was a significant difference in osseous pseudoprogression–free survival between single- and multifraction regimens ( P = .005). In lesions demonstrating osseous pseudoprogression, time-to-peak size occurred between 9.7 and 24.4 weeks after spine stereotactic radiosurgery (mean, 13.9 weeks; 95% CI, 8.6–19.1 weeks). The peak lesion size was between 4 and 10 mm larger than baseline. Most lesions returned to baseline size between 23 and 52.4 weeks following spine stereotactic radiosurgery. CONCLUSIONS: Progression on MR imaging performed between 3 and 6 months following spine stereotactic radiosurgery should be treated with caution because osseous pseudoprogression may be seen in more than one-third of these lesions. Single-fraction spine stereotactic radiosurgery may be associated with osseous pseudoprogression. The possibility of osseous pseudoprogression should be incorporated into the prospective criteria for assessment of local control following spine stereotactic radiosurgery.

Purpose Maintenance of Certification (MOC) recognizes that in addition to medical knowledge, several essential elements involved in delivering quality care must be developed and maintained throughout one’s career. The MOC process is designed to facilitate and document the professional development of each American Board of Radiology (ABR) diplomate through its focus on the essential elements of quality care in Diagnostic Radiology, its subspecialties, Radiation Oncology, and Radiologic Physics. The initial elements of the ABR MOC program have been developed in accord with guidelines of the American Board of Medical Specialties (ABMS). Further details will be developed as the process evolves.

Maintenance of certification (MOC) recognizes that in addition to medical knowledge, several essential elements involved in delivering quality care must be developed and maintained throughout one's career. The MOC process is designed to facilitate and document the professional development of each American Board of Radiology (ABR) diplomate through its focus on the essential elements of quality care in diagnostic radiology, its subspecialties, radiation oncology, and radiologic physics. The initial elements of the ABR's MOC program have been developed in accord with guidelines of the American Board of Medical Specialties. Further details will be developed as the process evolves.

The purpose of this study was to determine the frequency, radiographic findings, and clinical significance of a pulmonary embolism of cement occurring during percutaneous vertebroplasty or kyphoplasty as detected on conventional chest radiography.Chest radiographs were obtained after 69 percutaneous vertebroplasty procedures in 64 patients. Chest radiographs were reviewed retrospectively for the presence of pulmonary emboli of cement, and findings were assessed. The frequency was calculated from the cases treated. Medical records were reviewed for procedure-related complications.The emboli of cement were noted radiographically in three (4.6%) of 65 procedures performed in our institution. All patients with cement emboli had multiple myeloma. The chest radiographic findings were multiple radiographically dense opacities with a tubular and branching shape that were scattered sporadically or distributed diffusely throughout the lungs. All patients with cement pulmonary embolism remained asymptomatic. A correlation of embolism of cement to lungs was found with paravertebral venous cement leak (p0.001) but not with the number of vertebral bodies treated (p = 0.185) or with the type of procedure performed-kyphoplasty versus vertebroplasty (p = 0.98).Pulmonary embolism of cement is seen in 4.6% of patients after percutaneous vertebroplasty or kyphoplasty. The characteristic radiographic findings should be recognized by radiologists.

Lifelong learning is critical to radiology and the method by which, as professionals, we have kept up to date on new knowledge and developments. The American Board of Medical Specialists and the American Board of Radiology, along with other professional societies such as the Council of Medical Specialty Societies and the ACR, identified a need and an opportunity to serve the public and our profession through the Maintenance of Certification (MOC) initiative. These issues of lifelong learning, public concern, and MOC-and their interrelationship-are discussed. Lifelong learning is defined as a continuation of medical education with an ongoing process of professional development along with self-assessment, which enables physicians to maintain the requisite knowledge, skills, and professional standards. Continuing professional development can be grouped into three categories: formal, nonformal, and informal learning. Examples from the author's career illustrate key points. Future technologies and scientific discoveries affect radiology and make the commitment to lifelong learning even more critical. The challenge will be the maintenance of specialty certification and its components and competencies, along with the attainment of knowledge and the skills necessary in our unique practices for quality patient care in the evolving health care environment. These are important challenges to our boards, professional societies, specialty societies, institutions, and practicing community. It is critical to participate actively in these organizations and processes to continue development of the MOC initiative, because it is beneficial to patients, applicable to practicing physicians, and credible to public interests.

Numerous primary bone tumors are encountered on (18)F-FDG PET/CT, and many are FDG avid. The degree of FDG uptake in bone tumors does not necessarily reflect malignant potential. In conjunction with radiographs, evaluation of morphologic characteristics on the CT portion of PET/CT scans is important for characterization of the lesions. FDG PET/CT has been found to be useful for staging and has also been found to reflect prognosis in some primary bone malignancies. The purpose of this article is to familiarize the reader with topics regarding FDG PET/CT and both malignant and benign primary bone tumors.FDG uptake alone is not adequate for characterizing primary bone tumors, and morphologic evaluation is an important factor in the interpretation of PET/CT scans. After diagnosis, FDG avidity and morphologic features can play an important role in staging and determining response to therapy. On completion of this article, readers should have an improved ability to evaluate the FDG uptake and CT morphologic features of malignant and benign primary bone tumors. Readers should also have a better understanding of the potential role of FDG PET/CT in the management of patients with osteosarcoma and Ewing sarcoma.

3 nosed lesions are best divided into biologically aggressive or nonaggressive categories. Biopsy is indicated if the lesion is aggressive. Otherwise, watchful waiting with follow-up imaging can be pursued. Aggressive features are detected on radiographs by evaluation of imaging characteristics, such as the appearance of the margin, cortical expansion, and periosteal reaction. Clinical examination findings, such as pain, are also contributory.

The evolution of the Armed Forces Institute of Pathology (AFIP) has played an important role in the history of pathology education and in radiologic pathology correlation in the United States. From its humble beginnings as a museum, showcasing dried and varnished morbid specimens--human relics of the Civil War, the institute became a leader in pathology. Later, it became a center of instruction for radiology residents seeking to understand the pathologic findings that underlay the radiologic appearance of disease. Images were gathered by the AFIP and the American Registry of Pathology (ARP) and have been used in research and education in radiology and other fields (ophthalmology, otalaryngology, dermatology, obstetrics and gynecology, and surgery). Despite the contributions of the AFIP, the ARP, and the Radiologic Pathology Correlation Course, high-ranking members of the military and the federal government frowned on a military-owned educational system that also served civilians. Although support from the radiology community dissuaded military officers and federal officials from taking action against the participation of civilians, the 2005 Base Realignment and Closure (BRAC) provisions mandated the disestablishment of the AFIP, forcing the redistribution of some of its resources to other military-only organizations and disbanding other AFIP functions. To ensure that the correlation course, known to radiology residents as the "rad-path" course, was not a casualty of the BRAC, the American College of Radiology (ACR) and leaders of the AFIP and ARP agreed that the ACR should continue this vital educational endeavor. In January 2011, the American Institute for Radiologic Pathology of the ACR debuted and successfully instructed 268 radiology residents, including 40 international residents. The faculty and staff, who had been part of the course at the AFIP, continue to help enrich and improve the course established by their predecessors.

Soft tissue and osseous sarcomas of the extremities are uncommon malignancies that represent very important diagnostic entities because of their aggressive nature. Radiologic investigations, including plain film, computed tomography, contrast-enhanced magnetic resonance imaging; scintigraphy, ultrasound, and positron emission tomography–computed tomography, play critical roles in providing a differential, establishing the diagnosis, demonstrating prognostic characteristics, and tailoring tumor treatment. The purpose of this review is to describe the most common soft tissue and osseous sarcomas of the extremities, with emphasis on their plain film and magnetic resonance imaging characteristics with the aim of aiding the reader to accurately describe the important imaging features and generate an appropriate differential diagnosis to aid the referring clinician with prompt appropriate management and treatment.

We describe the imaging and pathological features of a rare case of sacral hibernoma that was discovered incidentally in a patient with low back pain. The benign-appearing, small intraosseous lesion in the sacrum was sclerotic on CT. MRI revealed that the lesion was heterogeneously hyperintense on T1W (lower in intensity than subcutaneous fat) and heterogeneously hypointense on fat-saturated T2W and STIR images. It showed mild heterogeneous enhancement on the post-contrast fat-saturated T1 MR images due to increased vascularity. A biopsy of the lesion was performed. The biopsy specimen demonstrated multivacuolated cells with immunohistochemical features of brown adipose tissue consistent with hibernoma.

To evaluate the effect of half-dose intravenous gadolinium contrast on the enhancement of bone and soft tissue tumors. This study is HIPAA compliant and informed consent was waived by the institutional review board. An institutional database search was performed over a 1-year period for patients with full- and half-dose MR examinations performed for musculoskeletal oncologic indications. Examination pairs that were identical with regard to field strength and presence or absence of fat saturation were included, resulting in 29 paired examinations. When multiple, the lesion that was best delineated and enhanced well on the first examination in the pair was chosen, yielding 17 bone and 12 soft tissue. Five musculoskeletal radiologists blinded to dosages were asked to assess for a difference in enhancement when comparing the lesion on both examinations and to rate the degree of difference on a three-point scale. They were also asked to identify the examination on which the lesion enhanced less (tallied as low dose). Results were analyzed with the exact binomial test. The readers perceived an enhancement difference in 41% (59/145) of studies (p = 0.03) and the majority were rated as “mild” (66%, 39/59). The readers did not accurately identify the low-dose examinations (54% correctly identified, 32/59, p = 0.60). Half-dose gadolinium enhancement of lesions could not be accurately distinguished from full-dose enhancement upon review of the same lesion imaged at both concentrations.

Melnick-Needles syndrome is a rare connective tissue disorder producing somatic abnormalities with characteristic radiographic features. There are less than 35 documented cases reported to date. We present four new cases of Melnick-Needles Syndrome, one of which is the first reported Asian-ancestry patient. Two girls are daughters of one of Needle's original patients from family #2. Two others, from unrelated non-affected families, probably represent new mutations. All have characteristic radiographic features of the disorder.

To determine if the location of the point of maximum standardized uptake value (SUVmax) being included in or not included in the histopathologic slab section corresponded to tumor necrosis or survival.Twenty-nine osteosarcoma patients underwent post-chemotherapy [fluorine-18]-fluoro-2-deoxy-D: -glucose (FDG) positron-emission tomography-computed tomography (PET/CT) prior to resection. PET/CT images were correlated with slab-section location as determined by photographs or knowledge of specimen processing. The location of the point of SUVmax was then assigned as being 'in' or 'out' of the slab section. Cox's proportional hazard regression was used to evaluate relationships between the location and value of SUVmax and survival. Logistic regression was employed to evaluate tumor necrosis.No correlation was found between the SUVmax location and survival or tumor necrosis. High SUVmax correlated to poor survival.High SUVmax value correlated to poor survival. Minimal viable tumor (10%) following chemotherapy is a known indicator of poor survival. No correlation was found between the location of SUVmax and survival or tumor necrosis. Therefore, the SUVmax value either does not correspond to a sufficient number of tumor cells to influence tumor necrosis measurement or it was included in the out-of-slab samples that were directed to viable-appearing areas of the gross specimen. Since high SUVmax has been previously found to correspond to poor tumor necrosis, and tumor necrosis is simply an estimate of the amount of viable tumor, SUVmax likely represents many viable tumor cells. Therefore, when not in the slab section, SUVmax was likely included in the tumor necrosis measurement through directed sampling, validating our current method of osteosarcoma specimen analysis.

Purpose To develop and demonstrate the feasibility of multisequence and multiplanar MRI for whole-body cancer detection. Materials and Methods Two fast Dixon-based sequences and a diffusion-weighted sequence were used on a commercially available 1.5 T scanner for whole-body cancer detection. The study enrolled 19 breast cancer patients with known metastases and in multistations acquired whole-body axial diffusion-weighted, coronal T2-weighted, axial/sagittal pre- and postcontrast T1-weighted, as well as triphasic abdomen images. Three radiologists subjectively scored Dixon images of each series for overall image quality and fat suppression uniformity on a 4-point scale (1 = poor, 2 = fair, 3 = good, and 4 = excellent). Results Eighteen of the 19 patients completed the whole-body MRI successfully. The mean acquisition time and overall patient table time were 46 ± 3 and 69 ± 5 minutes, respectively. The average radiologists' scores for overall image quality and fat suppression uniformity were both 3.4 ± 0.5. The image quality was consistent between patients and all completed whole-body examinations were diagnostically adequate. Conclusion Whole-body MRI offering essentially all the most optimal tumor-imaging sequences in a typical 1-hour time slot can potentially become an appealing “one-stop-shop” for whole-body cancer imaging. J. Magn. Reson. Imaging 2009;29:1154–1162. © 2009 Wiley-Liss, Inc.

OBJECTIVE. The purpose of this study is to report the radiographic changes seen in chronic sclerosing osteitis of the diaphysis of tubular bones during progression or healing, with CT and MRI correlation. Chronic sclerosing osteitis is an inflammatory condition of bone that can be considered a pediatric subset of the synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) spectrum of disease. Previous descriptions of long-bone involvement focus predominately on metaphyseal lesions. Eleven diaphyseal lesions in seven patients (age range, 13 months–14.5 years) were followed.CONCLUSION. The marked degree of cortical hyperostosis, medullary narrowing, and cortical lucencies seen in eight of 11 lesions is helpful for recognition of diaphyseal chronic sclerosing osteitis. Early identification of the disorder can prevent unnecessary repeat invasive procedures.

We report a case of amyloid arthropathy in a patient with multiple myeloma. Amyloid arthropathy is a very rare condition that may be associated with multiple myeloma. It presented in our patient as soft tissue masses around joints and eroding into adjacent bones. We found it to be hypermetabolic on fused positron emission tomography and computed tomographic scanning.