ACR Appropriateness Criteria® Shoulder Pain-Atraumatic.

Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Morphology of the Lesser Tuberosity and Intertubercular Groove in Patients With Arthroscopically Confirmed Subscapularis and Biceps Tendon Pathology.

PURPOSE: To evaluate for an association between the morphology of the lesser tuberosity and intertubercular groove and subscapularis tendon tears and biceps tendon pathology. METHODS: Sixty-six patients with arthroscopically confirmed subscapularis tendon tears were compared with 59 demographically matched control patients who underwent magnetic resonance imaging or computed tomography arthrography examination of the shoulder. Measurements of the lesser tuberosity and intertubercular groove included maximum depth of the intertubercular groove, intertubercular groove depth at the midpoint of the glenoid, lesser tuberosity length, length from the top of the humeral head to the point of maximum depth of the intertubercular groove, length from the top of the humeral head to the top of the lesser tuberosity, and medial wall angle and depth. RESULTS: Patients with subscapularis tears showed a significantly decreased depth of the intertubercular groove at the mid glenoid (P = .01), shorter length of the lesser tuberosity (P = .002), and greater distance from the top of the humeral head to the top of the lesser tuberosity (P = .02). There was a trend toward a decreased medial wall angle (P = .07) and greater distance from the top of the humeral head to the point of maximum intertubercular groove depth (P = .06). Patients with biceps tendon pathology showed a significantly decreased depth of the intertubercular groove at the mid glenoid (P = .001), shorter length of the lesser tuberosity (P = .0003), greater distance from the top of the humeral head to the top of the lesser tuberosity (P = .01), and decreased medial wall angle (P = .01) and depth (P = .03). CONCLUSIONS: There are several morphologic factors related to the lesser tuberosity and intertubercular groove that are associated with both subscapularis tendon tears and biceps tendon pathology. LEVEL OF EVIDENCE: Level III, case-control study.

Clinical and radiologic features of extraskeletal myxoid chondrosarcoma including initial presentation, local recurrence, and metastases.

BACKGROUND: The aim of the study was to evaluate the clinical and imaging features of extraskeletal myxoid chondrosarcoma (EMC) including initial presentation, recurrence, and metastases. PATIENTS AND METHODS: In this institutional review board-approved retrospective study, imaging features of 13 patients with pathologically proven EMC seen from August 1995 to December 2011 were analyzed. The group included 3 women and 10 men and the mean age was 54 years (range 29-73 years). Imaging studies were evaluated by two radiologists in consensus. Location, size, and imaging features of primary tumors were recorded as well as the presence of recurrent disease and location of metastases. RESULTS: Among 13 patients, 3 died during the timeframe of this study. Nine patients had primary tumor in the lower extremity, and average tumor size was 9.3 cm (range 3.3-18 cm). On MRI, primary tumors were hyperintense on T2, isointense to muscle on T1, and demonstrated peripheral/septal enhancement. Three patients had local recurrence and 12 had metastatic disease, with lung involvement being the most common. Tumor density on contrast enhanced CT ranged from 8.2 to 82.9 Hounsfield unit (HU). FDG-PET/CT imaging was performed in 3 patients. One patient had no FDG avid disease and 2 patients had metastatic disease with standard uptake values (SUV) of 2.8 and 7.4. The patient with intense FDG uptake demonstrated more solid appearing tumor burden and had the shortest survival. CONCLUSIONS: EMC is a rare tumor that often occurs in the lower extremities and frequently metastasizes to the lungs. Increased tumor density and increased FDG uptake may be related to more aggressive disease.

Percutaneous imaging-guided cryoablation of liver tumors: predicting local progression on 24-hour MRI.

OBJECTIVE: The purpose of this study was to determine which MRI features observed 24 hours after technically successful percutaneous cryoablation of liver tumors predict subsequent local tumor progression and to describe the evolution of imaging findings after cryoablation. MATERIALS AND METHODS: Thirty-nine adult patients underwent technically successful imaging-guided percutaneous cryoablation of 54 liver tumors (hepatocellular carcinoma, 8; metastases, 46). MRI features pertaining to the tumor, ablation margin, and surrounding liver 24 hours after treatment were assessed independently by two readers. Fisher exact or Wilcoxon rank sum tests (significant p values < 0.05) were used to compare imaging features in patients with and without subsequent local tumor progression. Imaging features of the ablation margin, treated tumor, and surrounding liver were evaluated on serial MRI in the following year. RESULTS: A minimum ablation margin of 3 mm or less was observed in 11 (78.6%) of 14 tumors with and 15 of 40 (37.5%) without progression (p = 0.012). A blood vessel bridging the ablation margin was noted in 11 of 14 (78.6%) tumors with and nine of 40 (22.5%) without progression (p < 0.001). The incidence of tumor enhancement 24 hours after cryoablation was similar for tumors with (10/14, 71.4%) or without (25/40, 62.5%) local progression (p = 0.75). MRI enabled assessment of the entire cryoablation margin in 49 of 54 (90.7%) treated tumors. CONCLUSION: MRI features at 24 hours after liver cryoablation that were predictive of local tumor progression included a minimum ablation margin less than or equal to 3 mm and a blood vessel bridging the ablation margin. Persistent tumor enhancement is common after liver cryoablation and does not predict local tumor progression.

Uterine sarcomas: then and now.

OBJECTIVE: The purpose of this article is to provide an updated review of uterine sarcomas. The traditionally described neoplasms are reviewed as well as several recently characterized entities in terms of their imaging and clinical aspects. We attempt to provide a longitudinal imaging overview, from initial presentation to follow-up. Imaging features are also described of response to traditional therapeutic agents and newer targeted agents. CONCLUSION: A greater understanding of the pathogenesis has improved our ability to image and treat uterine sarcomas, both at initial staging and on follow-up. Targeted therapy is assuming an increasingly important role in the management of these lesions. It is imperative for radiologists to be aware of response characteristics and potential complications of these agents as well as conventional chemotherapeutic agents.

MRI contrast enhancement of malignant liver tumours following successful cryoablation.

OBJECTIVES: To assess the incidence and degree of MRI contrast enhancement in liver tumours following successful percutaneous cryoablation. METHODS: Thirty-eight patients with liver metastases (n = 29) or hepatocellular carcinoma (n = 9) underwent percutaneous cryoablation of 45 tumours between March 2004 and June 2009, with complete ablation zone coverage of the tumour and no local recurrence on follow-up imaging to date (range 3-60 months, mean 16). Contrast-enhanced MRI was used to assess 45 tumours at 24 h, 32 tumours at 2-4 months, and 21 tumours at 5-7 months. Percentage of tumours with contrast enhancement was assessed using dynamic spoiled gradient echo T1-weighted images. RESULTS: Twenty-four hours post-cryoablation, 23 out of 45 tumours (51%) enhanced compared with 42 out of 43 (98%) pre-ablation (p < 0.001). Mean percentage tumour enhancement decreased from 157% (range 26-745%) pre-ablation, to 107% (27-260%) at 24 h (p = 0.003), and 43% (24-103%) at 2-4 months (p < 0.001). The incidence and degree of tumour enhancement decreased through 5-7 months. CONCLUSIONS: Unlike previously reported studies of radiofrequency ablation, successful cryoablation of liver tumours is often associated with persistent tumour contrast enhancement on MRI performed at 24 h and decreasing over 2-7 months. KEY POINTS: • Liver neoplasms often demonstrate MRI contrast enhancement following successful percutaneous cryoablation. • This differs from radiofrequency ablation techniques where contrast enhancement suggests residual tumour • This difference could potentially lead to important errors in follow up strategies.