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.

Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2023-overview, and primary local imaging: how and where?

OBJECTIVES: Early, accurate diagnosis is crucial for the prognosis of patients with soft tissue sarcomas. To this end, standardization of imaging algorithms, technical requirements, and reporting is therefore a prerequisite. Since the first European Society of Musculoskeletal Radiology (ESSR) consensus in 2015, technical achievements, further insights into specific entities, and the revised WHO-classification (2020) and AJCC staging system (2017) made an update necessary. The guidelines are intended to support radiologists in their decision-making and contribute to interdisciplinary tumor board discussions. 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 were scored online by level of agreement (0 to 10) during two iterative rounds. Either "group consensus," "group agreement," or "lack of agreement" was achieved. RESULTS: Eight sections were defined that finally contained 145 statements with comments. Overall, group consensus was reached in 95.9%, and group agreement in 4.1%. This communication contains the first part consisting of the imaging algorithm for suspected soft tissue tumors, methods for local imaging, and the role of tumor centers. CONCLUSION: Ultrasound represents the initial triage imaging modality for accessible and small tumors. MRI is the modality of choice for the characterization and local staging of most soft tissue tumors. CT is indicated in special situations. In suspicious or likely malignant tumors, a specialist tumor center should be contacted for referral or teleradiologic second opinion. This should be done before performing a biopsy, without exception. CLINICAL RELEVANCE: The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability both in individual patients and in future studies on individualized strategies. KEY POINTS: • Ultrasound remains the best initial triage imaging modality for accessible and small suspected soft tissue tumors. • MRI is the modality of choice for the characterization and local staging of soft tissue tumors in most cases; CT is indicated in special situations. Suspicious or likely malignant tumors should undergo biopsy. • In patients with large, indeterminate or suspicious tumors, a tumor reference center should be contacted for referral or teleradiologic second opinion; this must be done before a biopsy.

Injuries in non-professional padel tennis players. Results of a survey of the Italian Federation of Tennis in Liguria, Italy.

BACKGROUND: To understand padel tennis injuries occurrence in Liguria, Italy. Paddle is a well know racquet sport, similar to tennis. padel tennis has been widely adopted in Liguria only in the last 4 years, however sport practice was largely reduced by the worldwide spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: A questionnaire (N.=19 questions) was sent to all members of the Italian Federation of Tennis involved in official tournaments of padel tennis. We collected data on the number of injuries, the most frequent injuries, their distribution, type, location, the moment at which these occurred, and the diagnostic modality used to make the diagnosis. RESULTS: A total of 800 Italian padel tennis players took part in the survey (mean age: 49±22 years). In total, 85 injuries were registered in 2020/2021 up to 1/6/2021. The majority of lesion was located on the lower limb N.=49/85 with the knee N.=16/49 highly affected. Then, the majority of lesion of the upper limb were localized al the elbow N.=22/36, the majority epicondylitis. CONCLUSIONS: Padel tennis injuries resulted more common in the lower limb and the elbow was the most affected area at the upper limb.

Maintenance treatment with subcutaneous immunoglobulins in the long-term management of anti-HMCGR myopathy.

We describe the clinical response to long-term subcutaneous immunoglobulins (SCIg) in anti-3­hydroxy-3-methyl-glutaryl-coenzyme-A-reductase (anti-HMCGR) myopathy previously treated with intravenous immunoglobulins (IVIg). We collected data from patients affected by anti-HMGCR myopathy, switched from IVIg to SCIg therapy, after achieving clinical stabilization. The Medical Research Council sum score, creatine kinase (CK) levels, and anti-HMGCR antibodies were used to assess the response. We identified three patients with anti-HMGCR myopathy treated with SCIg with a favourable clinical course, allowing the maintenance of clinical stability, the reduction or suspension of steroids therapy and in two of them a complete CK normalization. Finally, anti-HMGCR antibodies tested in all patients after 12 months from SCIg starting, showed a global decrease. SCIg represent an useful alternative to long-term IVIg as already well known in several autoimmune neuromuscular disorders and inflammatory myopathies with advantages of lower side effects and home self-administration.

A prospective comparative trial of adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts (ASTOUND-2).

BACKGROUND: Increased risk of breast cancer (BC) and increased risk of an interval BC at mammography screening are associated with high mammographic density. Adjunct imaging detects additional BCs not detected at mammography screening in women with dense breasts. AIM: The aim is to estimate the incremental cancer detection rate (CDR) and false-positive recall for each of tomosynthesis and ultrasound, as adjunct screening modalities in women with mammography-negative dense breasts. METHODS: A multicentre prospective comparative trial of adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts (ASTOUND-2) recruited asymptomatic women attending Italian breast screening services. All participants had independently interpreted tomosynthesis and ultrasound. Outcomes were ascertained from excision histopathology or completed assessment. Paired binary data were compared using McNemar's test. RESULTS: We recruited 5300 screening participants with median age of 50 (interquartile range 43-79) years who had negative mammography and dense breasts (April 2015-September 2017). Adjunct screening detected 29 additional BCs (27 invasive, 2 in situ): 12 detected on both tomosynthesis and ultrasound, 3 detected only on tomosynthesis, 14 detected only on ultrasound. Incremental CDR for tomosynthesis (+15 cancers) was 2.83/1000 screens (95% confidence interval [CI]: 1.58-4.67) versus ultrasound (+26 cancers) with an incremental CDR of 4.90/1000 screens (95% CI: 3.21-7.19), P = 0.015. Mean size of these cancers was 14.2 mm (standard deviation: 7.8 mm), and six had nodal metastases. Incremental false-positive recall was 1.22% (95% CI: 0.91%-1.49%) and differed significantly between tomosynthesis (0.30%) and ultrasound (1.0%), P < 0.001. CONCLUSIONS: Ultrasound detected more BCs but caused more false positives than tomosynthesis, underscoring trade-offs in screening outcomes when adjunct imaging is used for screening dense breasts.

Adjunct Screening With Tomosynthesis or Ultrasound in Women With Mammography-Negative Dense Breasts: Interim Report of a Prospective Comparative Trial.

PURPOSE: Debate on adjunct screening in women with dense breasts has followed legislation requiring that women be informed about their mammographic density and related adjunct imaging. Ultrasound or tomosynthesis can detect breast cancer (BC) in mammography-negative dense breasts, but these modalities have not been directly compared in prospective trials. We conducted a trial of adjunct screening to compare, within the same participants, incremental BC detection by tomosynthesis and ultrasound in mammography-negative dense breasts. PATIENTS AND METHODS: Adjunct Screening With Tomosynthesis or Ultrasound in Women With Mammography-Negative Dense Breasts is a prospective multicenter study recruiting asymptomatic women with mammography-negative screens and dense breasts. Eligible women had tomosynthesis and physician-performed ultrasound with independent interpretation of adjunct imaging. Outcome measures included cancer detection rate (CDR), number of false-positive (FP) recalls, and incremental CDR for each modality; these were compared using McNemar's test for paired binary data in a preplanned interim analysis. RESULTS: Among 3,231 mammography-negative screening participants (median age, 51 years; interquartile range, 44 to 78 years) with dense breasts, 24 additional BCs were detected (23 invasive): 13 tomosynthesis-detected BCs (incremental CDR, 4.0 per 1,000 screens; 95% CI, 1.8 to 6.2) versus 23 ultrasound-detected BCs (incremental CDR, 7.1 per 1,000 screens; 95% CI, 4.2 to 10.0), P = .006. Incremental FP recall occurred in 107 participants (3.33%; 95% CI, 2.72% to 3.96%). FP recall (any testing) did not differ between tomosynthesis (FP = 53) and ultrasound (FP = 65), P = .26; FP recall (biopsy) also did not differ between tomosynthesis (FP = 22) and ultrasound (FP = 24), P = .86. CONCLUSION: The Adjunct Screening With Tomosynthesis or Ultrasound in Women With Mammography-Negative Dense Breasts' interim analysis shows that ultrasound has better incremental BC detection than tomosynthesis in mammography-negative dense breasts at a similar FP-recall rate. However, future application of adjunct screening should consider that tomosynthesis detected more than 50% of the additional BCs in these women and could potentially be the primary screening modality.

Elbow US: Anatomy, Variants, and Scanning Technique.

As with other musculoskeletal joints, elbow ultrasonography (US) depends on the examination technique. Deep knowledge of the relevant anatomy, such as the bone surface anatomy, tendon orientation, nerves, and vessels, is crucial for diagnosis. It is important to be aware of the primary imaging pitfalls related to US technique (anisotropy) in the evaluation of deep tendons such as the distal biceps and peripheral nerves. In this article, US scanning technique for the elbow as well as the related anatomy, primary variants, and scanning pitfalls are described. In addition, an online video tutorial of elbow US describes a possible approach to elbow evaluation. Online supplemental material is available for this article.

Fascicular ratio: a new parameter to evaluate peripheral nerve pathology on magnetic resonance imaging: a feasibility study on a 3T MRI system.

The objective of the study was to define and quantitatively evaluate the fascicular ratio (FR) on magnetic resonance imaging (MRI) in patients with peripheral neuropathies compared with healthy controls. Forty control subjects (20 women, 20 men; age, 44.6 ± 13.4 years) and 40 patients with peripheral neuropathy (22 women, 18 men; age, 50.3 ± 10.2 years) were examined with a standard 3T MRI protocol. With customized software (with semiautomatic and automatic interface), the hypointense and hyperintense areas of the peripheral nerves corresponding to fascicular and nonfascicular tissue were examined on T1-weighted sequences. The ratio of fascicular pixels to total pixels was called FR. Correlation with FR calculated on high-resolution ultrasound was performed. The statistical analysis included the Mann-Whitney U test of controls versus patients, the receiver operating characteristic (ROC) analysis, and the subgroup analysis of patients according to etiologies of neuropathy. Intraobserver and interobserver agreement was calculated based on the evaluation made by 3 readers. Finally, a complete automatic evaluation was performed. On MRI, FRs were significantly increased in patients compared with controls (FR, 76.7 ± 15.1 vs 56 ± 12.3; P < 0.0001 for the semiautomatic interface; and FR 66.3 ± 17.5 vs 47.8 ± 18.4; P < 0.0001 for the automatic interface). The increase in FR was caused mainly by an increase in the hypointense part of the nerve. This observation was valid for all causes of neuropathies. ROC analysis found an area under the curve of 0.75 (95% confidence interval, 0.44-0.81) for FR to discriminate neuropathy from control. The correlation coefficient between MRI and ultrasound was significant (r = 0.49; 95% confidence interval for r, 0.21-0.70; P = 0.012). With the semiautomated evaluation, the mean intraobserver agreement was good (K = 0.86). The interobserver agreements were also good (reader 1 vs reader 2, k = 0.71; reader 2 vs reader 3, k = 0.78; reader 3 vs reader 1, k = 0.71). There were no statistically significant differences between the results obtained using the 2 methods. FR calculation on MRI is feasible, and it may be used in adjunct to standard MRI evaluation in peripheral nerve disorders.