The role of conventional radiography to assess the outcome of oncologic skeletal reconstructions of lower limbs aided by vascularized fibular autograft.

INTRODUCTION: Vascularized fibular autografts (VFA) are used in the oncologic skeletal reconstructions of long bones, alone or combined with massive bone allografts (MBA). Data regarding the role of imaging in assessing these complex skeletal reconstructions are lacking, and have mainly focused on Computed Tomography (CT). Our aim was to evaluate if early conventional radiography (CR) findings are correlated with the outcome of these skeletal reconstructions. MATERIALS AND METHODS: All consecutive patients who underwent oncologic resection of lower limbs long bones followed by VFA reconstruction were included in this single-center retrospective study. We compared the CR obtained immediately after surgery with the CR at the 6-month control, as well as the CR at 6 months with the CT at 6 months when available. The following scores were assigned to the VFA: 0 (unchanged), 1 (osteopenia-cortical bone thinning), 2 (increase in bone density-cortical thickening). We then investigated whether this score correlated with the implant outcome within 12 months (optimal integration, suboptimal integration, integration requiring further surgery or lack of integration) using Kaplan-Meier and Cox regression analyses, considering the occurrence of integration and the duration time before the surgical removal of the whole bone reconstruction. RESULTS: Forty-five patients were included (32 men [71.1%], mean age 14.6 years), 26 affected by osteosarcoma, 14 by Ewing sarcoma, 3 by adamantinoma and 2 operated for the failure of previous reconstructions for bone sarcoma. VFA changes on 6-month CR were significantly associated with optimal integration of the implants (log-rank P = 0.0137, multivariate Hazard ratio = 7.62, 95% confidence interval = 1.13-51.25). None of the other clinical and surgical features were associated with the implant outcome. The findings on 6-month CR and CT follow-up were not significantly different. CT at 6 months was available in 36 patients (80.0%). CONCLUSION: The assessment of VFA morphological changes on CR performed at 6 months can predict the outcome of the skeletal implant. This data should be considered for clinical decision-making, selecting patients requiring additional images (CT), and possible subsequent revision surgical procedures.

Magnetic resonance imaging of soft tissue sarcoma: features related to prognosis.

Magnetic Resonance Imaging is a fundamental tool in the evaluation of soft tissue sarcoma. Imaging features are relevant for the assessment of treatment strategies, surgical planning and also for patients' prognosis prediction. Among soft tissue sarcoma and also other malignancies, the size of the mass is usually considered the prognostic key element in diagnostic imaging. Moreover, several other features should be obtained from MRI studies with prognostic implications in all type of soft tissue sarcoma: peritumoral enhancement, signs of necrosis, deep location, ill-defined borders/signs of infiltrations. Focusing on soft tissue sarcoma subtypes, some other magnetic resonance imaging features are more specific and related to prognosis. In myxofibrosarcoma the magnetic resonance imaging "tail sign" and a "water-like" appearance on fluid-sensitive sequences, due to rich myxoid matrix content, are both associated with higher risk of local recurrence after surgical excision; nevertheless, the "tail sign" is also related to a higher risk of distant metastases at diagnosis. The "tail sign" is associated with higher risk of local recurrence after surgical excision in undifferentiated pleomorphic sarcoma as well. In patients affected by synovial sarcoma, the "triple sign" identifiable in magnetic resonance imaging (T2w sequences) is associated with decreased disease-free survival and indicates the simultaneous presence of solid cellular elements (intermediate signal intensity), hemorrhage or necrosis (high signal intensity) and fibrotic regions (low signal intensity). In addition, absence of calcifications are associated with reduced disease-free survival in patients affected by synovial sarcoma. Signal heterogeneity is associated with worst prognosis in all type of soft tissue sarcoma, particularly in myxoid liposarcoma. In recent years, several new quantitative tools applied on magnetic resonance imaging have been proved to predict patients' prognosis. Above all the new tools, radiomics seems to be one of the most promising, and, has been proved to have the capability in discriminating low-grade from high-grade soft tissue sarcomas. Therefore, magnetic resonance imaging studies in patients with soft tissue sarcoma should be accurately evaluated and their results should be taken into account for prognostic assessment.

The triple rule out CT in acute chest pain: a challenge for emergency radiologists?

PURPOSE: To evaluate the feasibility of triple rule out computed tomography (TRO-CT) in an emergency radiology workflow by comparing the diagnostic performance of cardiovascular and general radiologists in the interpretation of emergency TRO-CT studies in patients with acute and atypical chest pain. METHODS: Between July 2017 and December 2019, 350 adult patients underwent TRO-CT studies for the assessment of atypical chest pain. Three radiologists with different fields and years of expertise (a cardioradiologist-CR, an emergency senior radiologist-SER, and an emergency junior radiologist-JER) retrospectively and independently reviewed all TRO-CT studies, by trans-axial and multiplanar reconstruction only. Concordance rates were then calculated using as reference blinded results from a different senior cardioradiologist, who previously evaluated studies using all available analysis software. RESULTS: Concordance rate was 100% for acute aortic syndrome (AAS) and pulmonary embolism (PE). About coronary stenosis (CS) for non-obstructive (<50%), CS concordance rates were 97.98%, 90.91%, and 97.18%, respectively, for CR, SER, and JER; for obstructive CS (>50%), concordance rates were respectively 88%, 85.7%, and 71.43%. Moreover, it was globally observed a better performance in the evaluation of last half of examinations compared with the first one. CONCLUSIONS: Our study confirm the feasibility of the TRO-CT even in an Emergency Radiology department that cannot rely on a 24/7 availability of a dedicated skilled cardiovascular radiologist. The "undedicated" radiologists could exclude with good diagnostic accuracy the presence of obstructive stenosis, those with a clinical impact on patient management, without needing time-consuming software and/or reconstructions.

Autoimmune comorbidities in multiple sclerosis: what is the influence on brain volumes? A case-control MRI study.

BACKGROUND: Several studies indicated that multiple sclerosis (MS) is frequently associated with other autoimmune diseases. However, it is little known if the coexistence of these conditions may influence the radiologic features of MS, and in particular the brain volumes. OBJECTIVES: To evaluate the effect of autoimmune comorbidities on brain atrophy in a large case-control MS population. METHODS: A group of MS patients affected by a second autoimmune disorder, and a control MS group without any comorbidity, were recruited. Patients underwent a brain MRI and volumes of whole brain (WB), white matter (WM), and gray matter (GM) with cortical GM were estimated by SIENAX. RESULTS: The sample included 286 MS patients, of which 30 (10.5%) subjects with type 1 diabetes (T1D), 53 (18.5%) with autoimmune thyroiditis (AT) and 4 (0.1%) with celiac disease. Multiple regression analysis found an association between T1D and lower GM (p = 0.038) and cortical GM (p = 0.036) volumes, independent from MS clinical features and related to T1D duration (p < 0.01), while no association was observed with AT and celiac disease. CONCLUSIONS: Our data support the importance of considering T1D as possible factors influencing the brain atrophy in MS. Further studies are needed to confirm our data and to clarify the underlying mechanisms.