Soft tissue tumor imaging in adults: whole-body staging in sarcoma, non-malignant entities requiring special algorithms, pitfalls and special imaging aspects. Guidelines 2024 from the European Society of Musculoskeletal Radiology (ESSR).

OBJECTIVES: The revised European Society of Musculoskeletal Radiology (ESSR) consensus guidelines on soft tissue tumor imaging represent an update of 2015 after technical advancements, further insights into specific entities, and revised World Health Organization (2020) and AJCC (2017) classifications. This second of three papers covers algorithms once histology is confirmed: (1) standardized whole-body staging, (2) special algorithms for non-malignant entities, and (3) multiplicity, genetic tumor syndromes, and pitfalls. MATERIALS AND METHODS: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements that had undergone interdisciplinary revision were scored online by the level of agreement (0 to 10) during two iterative rounds, that could result in 'group consensus', 'group agreement', or 'lack of agreement'. RESULTS: The three sections contain 24 statements with comments. Group consensus was reached in 95.8% and group agreement in 4.2%. For whole-body staging, pulmonary MDCT should be performed in all high-grade sarcomas. Whole-body MRI is preferred for staging bone metastasis, with [18F]FDG-PET/CT as an alternative modality in PET-avid tumors. Patients with alveolar soft part sarcoma, clear cell sarcoma, and angiosarcoma should be screened for brain metastases. Special algorithms are recommended for entities such as rhabdomyosarcoma, extraskeletal Ewing sarcoma, myxoid liposarcoma, and neurofibromatosis type 1 associated malignant peripheral nerve sheath tumors. Satisfaction of search should be avoided in potential multiplicity. CONCLUSION: Standardized whole-body staging includes pulmonary MDCT in all high-grade sarcomas; entity-dependent modifications and specific algorithms are recommended for sarcomas and non-malignant soft tissue tumors. CLINICAL RELEVANCE STATEMENT: These updated ESSR soft tissue tumor imaging guidelines aim to provide support in decision-making, helping to avoid common pitfalls, by providing general and entity-specific algorithms, techniques, and reporting recommendations for whole-body staging in sarcoma and non-malignant soft tissue tumors. KEY POINTS: An early, accurate, diagnosis is crucial for the prognosis of patients with soft tissue tumors. These updated guidelines provide best practice expert consensus for standardized imaging algorithms, techniques, and reporting. Standardization can improve the comparability examinations and provide databases for large data analysis.

Standardized reporting of spine and sacroiliac joints in axial spondyloarthritis MRI: from the ESSR-Arthritis Subcommittee.

OBJECTIVES: Apply a modified Delphi-based approach and produce a practical, radiology-specific set of definitions for interpretation and standardization of the multiple MRI findings in axial spondyloarthritis (ax-SpA), specifically to aid the general radiologist with a musculoskeletal interest, working with gold standard basic MRI protocols. MATERIALS AND METHODS: We report the results of a modified Delphi-based consensus of 35 experts from 13 countries in the Arthritis Subcommittee of the European Society of Musculoskeletal Radiology (ESSR). Seventeen definitions were created (i.e., nine for the spine and eight for the sacroiliac joint) and two Delphi rounds were conducted on an electronic database, collated and revised by the project leader with agreement. Group leads were appointed for each definition following the first round. Final definitions included only those that reached a consensus > 80%; if > 50% agreed on exclusion consensus, definitions were excluded. Final results have been shared during the Arthritis meeting at the Annual ESSR Congress. RESULTS: Fourteen definitions, eight for the spine and six for the sacroiliac joint were agreed for standardized reporting. Andersson's, anterior corner sclerotic and costovertebral joint inflammatory lesions of the spine, with active and non-active erosions, and fat metaplasia of the sacroiliac joint reaching the highest consensus (≥ 95%). More than 50% of the experts agreed to exclude joint space inflammation in the sacroiliac joint and tissue backfill. Syndesmophytes reached 76% agreement. CONCLUSIONS: Agreed definitions by expert radiologists using a modified Delphi process, should allow standardized actionable radiology reports and clarity in reporting terminology of ax-SpA. CLINICAL RELEVANCE STATEMENT: The proposed definitions will support reporting from musculoskeletal and general radiologists working with gold-standard basic MRI, improve confidence in lesion assessment, and standardize terminology to provide actionable reports on MRI in patients with ax-SpA. KEY POINTS: Experts applied a modified Delphi method to optimize the definitions of MRI findings of ax-SpA. After two Delphi rounds and one in-person meeting, fourteen definitions reached the agreement threshold. These consensus-based definitions will aid in actionable reporting specifically for the general radiologist with a musculoskeletal interest.

Ankle and Foot: Focus on Inflammatory Disease.

The ankle and foot have numerous bones and complex joints that can be affected by several types of inflammatory arthritis with different patterns and various radiologic signs, depending on the phase of the disease. Involvement of these joints is most frequently seen in peripheral spondyloarthritis and rheumatoid arthritis in adults and juvenile idiopathic arthritis in children. Although radiographs are a mainstay in the diagnostic process, ultrasonography and especially magnetic resonance imaging allow early diagnosis and are crucial diagnostic tools. Some diseases have typical features based on target populations (e.g., adults versus children, men versus women), but others may have overlapping imaging characteristics. We highlight key diagnostic features and describe appropriate investigations to guide clinicians toward the correct diagnosis and provide support during disease monitoring.

Imaging update on soft tissue sarcoma.

Soft tissue sarcomas (STS) are rare tumours presenting as soft tissue lumps. Ultrasound is often the primary modality for the initial assessment, with MRI the mainstay for lesion characterisation. PET/CT along with other emerging MRI sequences are used in certain situations as an adjunct and problem solving tool in STS staging and assessment of disease recurrence. Recent advances include the promise of whole body MRI, hybrid PET/MRI, diffusion weighted imaging, dynamic contrast enhanced MRI and advances in artificial intelligence. This article discusses current concepts in extremity STS imaging and highlights recent advances.

Imaging update in spondyloarthropathy.

Although our understanding of axial spondyloarthropathy (axSpA) has increased recently, there has not been a concurrent improvement in patient diagnosis with delays contributing to patient morbidity. Imaging findings of axSpA can be subtle and may be dismissed often due to lack of understanding by reporters and importantly clinicians who do not suspect the disease. Recognition of the importance of imaging has led to the inclusion of MRI as part of the diagnostic criteria for axSpA. With this in mind, a number of advancements have been made in an attempt to increase our diagnostic accuracy on imaging. This article will give an overview of these techniques as well as a recap of the imaging features of axSpA.

Phosphaturic mesenchymal tumors: radiological aspects and suggested imaging pathway.

Phosphaturic mesenchymal tumors (PMTs) are rare mesenchymal neoplasms of soft tissue or bone origin that can give rise to a challenge in diagnostic imaging. These tumors are frequently associated with tumor-induced osteomalacia, also called oncogenic osteomalacia, which is a rare paraneoplastic syndrome characterized by ectopic secretion of fibroblast growth factor 23, a hormone that regulates serum phosphate level. PMTs show polymorphic features on both radiological findings and histological examination, causing problems in diagnosis owing to their similarity with other mesenchymal tumors. Thus, this paper aims to describe radiological aspects of PMTs and suggest an imaging pathway for accurate diagnosis throughout the evidence from the literature review.

Non-neoplastic Soft Tissue Tumors and Tumor-like Lesions.

Clinicians are commonly faced with patients presenting with a solitary palpable soft tissue mass. Most soft tissue lesions are benign, and not every mass is due to a neoplastic process. Many pathologies can mimic a malignant tumor. Despite appropriate clinicoradiologic assessment, these lesions can be mistaken for a soft tissue sarcoma and can lead to multiple investigations or an intervention, inconveniencing patients and leading to an increased health care cost. With the relevant clinical history, clinical examination, and specific imaging characteristics, the diagnosis can be narrowed. We present a pictorial review of soft tissue sarcoma mimics with guidance on appropriate differential diagnoses.

Concurrent Joint Hypermobility Syndrome and Spondyloarthropathy: A New Spondyloarthropathy Subgroup With a Less Severe Disease Phenotype?

BACKGROUND: The coexistence of joint hypermobility syndrome (JHS) and spondyloarthropathy (SpA) presents a challenging clinical conundrum due to the contradictory clinical signs that may be present. Classic features such as restricted spinal movement or early morning back stiffness may not be present. Timely diagnosis and appropriate management of these patients are difficult as they tend to have lower scores on validated objective measures. METHODS: We performed a medical records review study to identify patients with both JHS and SpA who had presented to the Leicester Spondyloarthropathy clinic. Patients were diagnosed with axial SpA if they met the Assessment of SpondyloArthritis international Society classification criteria. Their imaging was reviewed by a consultant musculoskeletal radiologist. RESULTS: Four cases were identified from the patient database (female; average age, 37.5 years). All patients presented with lower back pain or sacroiliac joint pain but preserved spinal movement with a negative Schober's test. Two had a history of symptoms for more than 10 years. All had a Beighton score of greater than 6. Three of the patients were HLA positive, and 3 had a positive family history. All patients thus far have had their symptoms adequately controlled on nonsteroidal anti-inflammatory drugs and physiotherapy. CONCLUSIONS: The coexistence of JHS and SpA is rare but important to recognize. These patients are difficult to diagnose as they may present late because of preserved spinal movements. It is unclear whether the preserved flexibility masks the true extent of disease or whether clinically they represent a less severe disease phenotype.

Anterior Chest Wall in Axial Spondyloarthritis: Imaging, Interpretation, and Differential Diagnosis.

Anterior chest wall (ACW) inflammation is not an uncommon finding in patients with axial spondyloarthritis (ax-SpA) and reportedly occurs in 26% of these patients. Radiologists may only be familiar with spinal and peripheral joint imaging, possibly due to the inherent challenges of ACW imaging on some cross-sectional imaging modalities. Knowledge of relevant joint anatomy and the location of sites of inflammation allows the interpreting radiologist to better plan appropriate imaging tests and imaging planes. Accurate assessment of disease burden, sometimes in the absence of clinical findings, may alert the treating rheumatologist, allowing a better estimation of disease burden, increased accuracy of potential imaging scoring systems, and optimize assessment and response to treatment. This article reviews salient anatomy and various imaging modalities to optimize diagnosis, important differential diagnoses, and the interpretation of ACW imaging findings in ax-SpA.

Classification Terminology and Definitions in Reporting of MRI in Axial Spondyloarthritis.

Spondyloarthritis (SpA) is a group of chronic inflammatory conditions which severely impact quality of life. Several criteria have been developed in the past to aid the diagnosis of SpA based on symptoms and radiographic changes during the course of the disease. However, it takes several years before structural changes manifest on conventional radiographs, leading to a diagnostic delay of 6 to 10 years. The use of MRI and its incorporation into the Assessment of Spondyloarthritis (ASAS) criteria, has radically changed the diagnosis of SpA in the last decade by allowing visualisation of both active and chronic inflammatory changes and enabling clinicians to recognise SpA during it's early stage and initiate treatment. An understanding of the various terminology used in the divisions of disease presentations and their relevant imaging findings are key, along with the use of clear definitions of structural and inflammatory changes on MRI, in ensuring accurate diagnosis and classification of SpA.

Percutaneous Ultrasound-Guided TOPAZ Radiofrequency Coblation: A Novel Coaxial Technique for the Treatment of Recalcitrant Plantar Fasciitis-Our Experience.

Various therapeutic options are available for treatment of recalcitrant plantar fasciitis. Studies using TOPAZ coblation (ArthroCare, Sunnyvale, CA) have had good early results. The current coblation technique involves a surgical incision or breach of the highly specialized plantar fat pad, which can be associated with risks. We describe a novel technique of ultrasound-guided percutaneous coblation with a lateral heel approach. Advantages include precise targeting of the plantar fascia by direct dynamic visualization of the coblation tip, a true percutaneous approach with a needle skin puncture (<5 mm), and preservation of the plantar fat pad by using a lateral heel approach.

Development and Preliminary Validation of a Digital Overlay-based Learning Module for Semiquantitative Evaluation of Magnetic Resonance Imaging Lesions in Osteoarthritis of the Hip.

OBJECTIVE: To develop and validate a knowledge transfer (KT) module aimed at enhancing feasibility and reliability of semiquantitative assessment of bone marrow lesions (BML) and synovitis-effusion using the Hip Inflammation Magnetic Resonance Imaging Scoring System (HIMRISS). METHODS: Three radiologists naive to the HIMRISS method reviewed the manuscript describing the method and then scored MRI scans from 16 patients with hip OA obtained at baseline and 8 weeks after intraarticular injection of corticosteroid. Readers then reviewed a KT module comprising an instructional presentation and 8 reference DICOM (digital imaging and communications in medicine) cases scored by 3 readers with expertise in the HIMRISS method, and then used electronic overlay software to score scans from 23 patients with OA. The same format was followed with a second group of 3 readers naive to HIMRISS using a KT module revised to incorporate the overlay with a Web-based DICOM viewer to enhance feasibility. Interobserver reliability was assessed with the intraclass correlation coefficient (ICC). RESULTS: In both exercises, reliability for baseline scores was excellent for femoral BML, very good for acetabular BML, and good for synovitis-effusion (overall ICC = 0.91, 0.89, 0.62, respectively) even without prior calibration using the KT module. However, reliability for detecting change was substantially worse than for expert readers, especially for acetabular BML and synovitis-effusion (overall ICC = 0.59 vs 0.19, and 0.42 vs 0.25, respectively). Reliability improved for detection of change in these lesions, especially after reader calibration with the revised KT module. CONCLUSION: Development and validation of a systematic method for KT may enhance external validation of certain imaging instruments.

Recommendations of the ESSR Arthritis Subcommittee for the Use of Magnetic Resonance Imaging in Musculoskeletal Rheumatic Diseases.

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee regarding the standards of the use of MRI in the diagnosis of musculoskeletal rheumatic diseases. The recommendations discuss (1) the role of MRI in current classification criteria of musculoskeletal rheumatic diseases (including early diagnosis of inflammation, disease follow-up, and identification of disease complications); (2) the impact of MRI on the diagnosis of axial and peripheral spondyloarthritis, rheumatoid arthritis, and juvenile spondyloarthritis; (3) MRI protocols for the axial and peripheral joints; (4) MRI interpretation and reporting for axial and peripheral joints; and finally, (5) methods for assessing MR images including quantitative, semiquantitative, and dynamic contrast-enhanced MRI studies.

The Influence of High-Impact Exercise on Cortical and Trabecular Bone Mineral Content and 3D Distribution Across the Proximal Femur in Older Men: A Randomized Controlled Unilateral Intervention.

Regular exercisers have lower fracture risk, despite modest effects of exercise on bone mineral content (BMC). Exercise may produce localized cortical and trabecular bone changes that affect bone strength independently of BMC. We previously demonstrated that brief, daily unilateral hopping exercises increased femoral neck BMC in the exercise leg versus the control leg of older men. This study evaluated the effects of these exercises on cortical and trabecular bone and its 3D distribution across the proximal femur, using clinical CT. Fifty healthy men had pelvic CT scans before and after the exercise intervention. We used hip QCT analysis to quantify BMC in traditional regions of interest and estimate biomechanical variables. Cortical bone mapping localized cortical mass surface density and endocortical trabecular density changes across each proximal femur, which involved registration to a canonical proximal femur model. Following statistical parametric mapping, we visualized and quantified statistically significant changes of variables over time in both legs, and significant differences between legs. Thirty-four men aged mean (SD) 70 (4) years exercised for 12-months, attending 92% of prescribed sessions. In traditional regions of interest, cortical and trabecular BMC increased over time in both legs. Cortical BMC at the trochanter increased more in the exercise than control leg, whereas femoral neck buckling ratio declined more in the exercise than control leg. Across the entire proximal femur, cortical mass surface density increased significantly with exercise (2.7%; p < 0.001), with larger changes (> 6%) at anterior and posterior aspects of the femoral neck and anterior shaft. Endocortical trabecular density also increased (6.4%; p < 0.001), with localized changes of > 12% at the anterior femoral neck, trochanter, and inferior femoral head. Odd impact exercise increased cortical mass surface density and endocortical trabecular density, at regions that may be important to structural integrity. These exercise-induced changes were localized rather than being evenly distributed across the proximal femur.

Ganglia arising from the transverse acetabular ligament: a report of two cases.

Ganglia arising from the hip are rare. Its diagnosis is difficult owing to the anatomic location. A high index of suspicion and high-resolution imaging is essential to make the diagnosis. Treatment depends on the size, location, and symptoms. This report is of 2 patients with ganglia arising from the transverse acetabular ligament.

Isolated posterior high ankle sprain: a report of three cases.

High ankle sprains are difficult to diagnose and account for 10% of all ankle sprains. A high index of suspicion is essential for diagnosis. High ankle sprains are managed symptomatically, with prolonged rehabilitation. The posterior inferior tibiofibular ligament is the strongest syndesmotic ligament; isolated injury of it is rare. We present 3 cases of isolated posterior high ankle sprain and discuss the relevant anatomy, mechanism of injury, and management.

High impact exercise increased femoral neck bone mineral density in older men: a randomised unilateral intervention.

INTRODUCTION: There is little evidence as to whether exercise can increase BMD in older men with no investigation of high impact exercise. Lifestyle changes and individual variability may confound exercise trials but can be minimised using a within-subject unilateral design (exercise leg [EL] vs. control leg [CL]) that has high statistical power. PURPOSE: This study investigated the influence of a 12month high impact unilateral exercise intervention on femoral neck BMD in older men. METHODS: Fifty, healthy, community-dwelling older men commenced a 12month high impact unilateral exercise intervention which increased to 50 multidirectional hops, 7days a week on one randomly allocated leg. BMD of both femurs was measured using dual energy X-ray absorptiometry (DXA) before and after 12months of exercise, by an observer blind to the leg allocation. Repeated measures ANOVA with post hoc tests was used to detect significant effects of time, leg and interaction. RESULTS: Thirty-five men (mean±SD, age 69.9±4.0years) exercised for 12months and intervention adherence was 90.5±9.1% (304±31 sessions completed out of 336 prescribed sessions). Fourteen men did not complete the 12month exercise intervention due to: health problems or injuries unrelated to the intervention (n=9), time commitments (n=2), or discomfort during exercise (n=3), whilst BMD data were missing for one man. Femoral neck BMD, BMC and cross-sectional area all increased in the EL (+0.7, +0.9 and +1.2 % respectively) compared to the CL (-0.9, -0.4 and -1.2%); interaction effect P<0.05. Although the interaction term was not significant (P>0.05), there were significant main effects of time for section modulus (P=0.044) and minimum neck width (P=0.006). Section modulus increased significantly in the EL (P=0.016) but not in the CL (P=0.465); mean change +2.3% and +0.7% respectively, whereas minimum neck width increased significantly in the CL (P=0.004) but not in the EL (P=0.166); mean changes being +0.7% and +0.3% respectively. CONCLUSION: A 12month high impact unilateral exercise intervention was feasible and effective for improving femoral neck BMD, BMC and geometry in older men. Carefully targeted high impact exercises may be suitable for incorporation into exercise interventions aimed at preventing fractures in healthy community-dwelling older men.

Dynamic ultrasound assessment of the effects of knee and ankle position on Achilles tendon apposition following acute rupture.

BACKGROUND: Previous reports have suggested that knee flexion improves tendon edge apposition following acute rupture of the Achilles tendon. The aim of the present study was to determine, with use of ultrasonography, the effects of knee and ankle position on the Achilles tendon gap distance in patients with an acute rupture. METHODS: Twenty-six patients with a unilateral acute complete Achilles tendon rupture that had been confirmed with ultrasonography were recruited within a week after the injury. The mean age at the time of presentation was forty-one years. Ultrasound measurements included the location of the rupture and the gap distance between the superficial tendon edges with the ankle in neutral and the knee extended. The gap distance was sequentially measured with the foot in maximum equinus at the ankle and with 0°, 30°, 60°, and 90° of knee flexion. RESULTS: The mean distance of the rupture from the calcaneal enthesis was 52 mm (range, 40 to 76 mm). The mean gap distance with the ankle in neutral and the knee extended was 12 mm (95% confidence interval, 10 to 13 mm). This distance decreased to 5 mm (95% confidence interval, 4 to 7 mm) when the foot was placed in maximum ankle equinus with 0° of knee flexion and to 4 mm (95% confidence interval, 3 to 5 mm) with 30° of knee flexion, 3 mm (95% confidence interval, 2 to 4 mm) with 60° of knee flexion, and 2 mm (95% confidence interval, 1 to 2 mm) with 90° of knee flexion. Expressing the reduction in gap distance with each successive position as a percentage of the gap distance with the knee extended and the ankle in neutral revealed a mean reduction of 55.7%, 64.4%, 75.4%, and 84.8% with maximum ankle equinus and 0°, 30°, 60°, and 90° of knee flexion, respectively. The difference in gap distance between each of these positions was significant (p < 0.05). CONCLUSIONS: Maximum ankle equinus alone significantly reduces the gap distance after acute Achilles tendon rupture. Increasing knee flexion further reduces the gap distance by small increments that, although significant, may not be clinically important.