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To determine the frequency of non-diagnostic and discordant results from bone and soft tissue biopsies performed at our institution over a 3-year period and to investigate whether implementation of a weekly musculoskeletal radiology-pathology correlation conference decreased the time to appropriate patient management in cases of discordance. Consecutive image-guided core needle biopsy results obtained over a 12 month period of time were reviewed in a retrospective fashion. Following implementation of the correlation conference, subsequent consecutive image-guided core needle biopsy results obtained over a 26 month period of time were reviewed in a prospective fashion. For non-diagnostic and discordant cases, the time in days from date of availability of the biopsy result to date of documentation of a specific follow-up action plan was recorded. Diagnostic yield was 96.5% and 94.9% for the retrospective and prospective periods, respectively. There were four discordant results in the retrospective cohort (1.7%) and seven discordant results in the prospective cohort (2.1%). Following implementation of the weekly correlation conference, there was significant decrease (p

Although primary bone tumors are relatively uncommon, appropriate imaging evaluation is essential when they are suspected or incidentally detected. In almost all cases, radiographs are the most appropriate initial imaging study for screening and characterization of primary bone tumors. Radiographs often provide sufficient information for diagnosis and to guide the treating clinician. However, when conventional radiographs alone are inadequate, they still often guide the selection of the most appropriate next step for advanced imaging. MRI and CT are typically the most appropriate next step. MRI provides excellent soft-tissue contrast allowing for evaluation of the tissue composition (such as fat, hemorrhage, fluid levels) and anatomic extent of bone tumors. CT provides complementary information, with its ability to detect subtle matrix mineralization or periosteal reaction that may not be seen on radiographs or MRI. This publication focuses on six common variants to guide diagnosis and management of primary bone tumors. In addition to conventional radiographs, appropriate use of MRI, CT, PET/CT, bone scan, and ultrasound are discussed. 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.

To describe the technique of iodine125 (I125) seed deployment into nonpalpable soft tissue masses under direct ultrasound (US) or CT guidance for intraoperative localization. Patients considered candidates for radioactive seed localization (RSL) based on advanced imaging findings underwent an ultrasound examination of the area of concern to verify sonographic visualization of the targeted mass. If the mass was not visible sonographically, CT was used for guidance. Patients were scheduled for surgery 1–4 days after seed implantation. Intraoperative frozen section pathological analysis was performed on all patients. Operative time, specimen volume, intraoperative margin status, and final margin status were recorded. Following the surgery, patients and surgeons completed satisfaction surveys. Ten patients underwent seed placement between 1 and 4 days prior to surgery. All patients had successful surgical resection of the targeted mass with removal of all implanted radioactive seed(s). There was no seed migration. Intraoperative frozen-section margins were negative (>2 mm) in 6/10 patients. Final surgical margins were negative in 9/10 patients. The patient with a positive margin at final pathology did not undergo further resection due to the benign nature of the mass. Patient and surgeon satisfaction survey results were highly positive. All four surgeons reported a strong preference for seed localization over wire localization. RSL is an effective, reliable, and safe technique for preoperative localization of nonpalpable soft tissue masses and yields high patient and surgeon satisfaction.

Epithelioid schwannoma is an uncommon benign peripheral nerve sheath tumor, with distinct morphological and pathological features. To our knowledge, the imaging features of epithelioid schwannoma have not been described. In this case report, we describe the imaging findings of a pathologically proven case of epithelioid schwannoma presenting as a slowly growing painless mass near the ankle. The MR imaging signs commonly associated with conventional schwannoma were absent. On correlative radiographs, there were intra-tumoral calcifications. Radiographs are an essential tool in the imaging evaluation of soft-tissue masses. Knowledge of soft-tissue tumor types that can be associated with intra-tumoral calcifications is helpful in honing the differential diagnosis.

ObjectiveBone marrow aspiration and concentration (BMAC) is becoming a more common regenerative therapy for musculoskeletal pathology. In our current pilot study, we studied patients with mild-to-moderate bilateral knee osteoarthritis, compared pain at 12-month follow-up between BMAC-injected and saline-injected knees, and examined cartilage appearance measured by magnetic resonance imaging (MRI) T2 quantitative mapping.DesignTwenty-five patients with mild-to-moderate bilateral osteoarthritic knee pain were randomized to receive BMAC into one knee and saline placebo into the other. Bone marrow was aspirated from the iliac crests, concentrated in an automated centrifuge, combined with platelet-poor plasma for knee injection, and compared with saline injection into the contralateral knee. Primary outcome measures were T2 MRI cartilage mapping at 6-month and Visual Analog Scale and Osteoarthritis Research Society International Intermittent and Constant Osteoarthritis Pain scores and radiographs at 12-month follow-up.ResultsConstant, intermittent, and overall knee pain remained significantly decreased from baseline at 12-month follow-up (all P ⩽ 0.01), with no apparent difference between BMAC- and saline-treated knees (all P ⩾ 0.54). A similar significant increase from baseline to 12-month follow-up regarding quality of life was observed for both BMAC- and saline-treated knees (all P ⩽ 0.04). T2 quantitative MRI mapping showed no significant changes as a result of treatment.ConclusionsBMAC is safe to perform and relieves pain from knee arthritis but showed no superiority to saline injection at 12-month follow-up. MRI cartilage sequences failed to show regenerative benefit with single BMAC injection. The mechanisms of action that led to pain relief remain unclear and warrant further studies.

Promising results reported with currently available total ankle arthroplasty designs have led to an increased use of such devices as an alternative to ankle arthrodesis. Despite recent improvements in implant design and surgical technique, complications associated total ankle arthroplasty devices continue to be reported. Postoperative evaluation of total ankle arthroplasties relies on a combination of clinical and radiologic assessment. Familiarity with commonly used current total ankle arthroplasty devices and appropriate postoperative imaging techniques is imperative for effective characterization of the expected postoperative imaging appearances of such devices and facilitating detection of potential postoperative complications.

Intraparenchymal hemorrhage (IPH) volume is a powerful predictor of 30-day mortality. Warfarin-related intracranial hemorrhage (ICH) has a higher mortality than ICH without anticoagulation, possibly due to continued growth after 24 h, larger average size, and extension to extraparenchymal compartments. We compared 2 methods of measuring ICH volume in patients with warfarin-related ICH. ICH volume was estimated using the ABC/2 method and a computer-assisted method (Analyze 6.0 software) applied to the initial head computed tomographic scans in a consecutive series of 8 patients with warfarin-related ICH. The 2 methods were compared for relative and absolute differences in estimated hematoma volumes. The ABC/2 method underestimated hematoma volume in 4 of 5 patients with IPH, inaccurately calculated intraventricular hemorrhage volume in 2 patients (overestimated by 9%, underestimated by 23%), and underestimated a complex subdural hematoma in 1 patient by 24% despite use of the Gebel modification. The mean percentage difference between the Analyze and ABC/2 methods was 24% in ellipsoid hemorrhages and 28% in nonellipsoid hemorrhages (P = 0.77). The mean of the absolute difference between the 2 methods was 6.7 cm3 in ellipsoid hemorrhages and 38.0 cm3 in nonellipsoid hemorrhages (P = 0.18). The ABC/2 method accurately and quickly estimates smaller, ellipsoid intraparenchymal hematomas but is inaccurate for larger, complex-shaped warfarin-related intraparenchymal, intraventricular, and subdural hematomas. Warfarin-related ICH mortality may be underestimated by the ABC/2 method because of larger, complex-shaped, and multicompartmental hematomas.

OBJECTIVE. The purpose of this article is to review the basic design features of second-generation total ankle arthroplasty components and to illustrate the normal and abnormal postoperative imaging features associated with such devices. The usefulness of CT in postoperative evaluation will be highlighted.CONCLUSION. Postoperative evaluation of the total ankle arthroplasty necessitates a familiarity with the various designs currently in use. Radiography serves as an integral component in the postoperative evaluation of such devices, with CT offering further characterization of radiographic abnormalities.

Pubic complications following radical prostatectomy are rare. Osteitis pubis typically presents with symptoms related to irritation of the pubic rami including pain with ambulation and adduction of the leg. A 60-year-old male with prostatic adenocarcinoma underwent uneventful robotic assisted laparoscopic prostatectomy. The patient noted the onset of severe pubic pain exacerbated by ambulation approximately one month post-surgery. An abdominal/pelvic CT scan was negative for acute pathology. Due to continued discomfort, a multiplanar MRI of the pelvis was performed with and without intravenous contrast material (20 ml Omniscan). The MRI demonstrated irregularity of the bladder base and proximal urethra with a fistulous tract extending anteriorly in direct communication with the pubic symphysis joint space. Vague periarticular marrow edema-like signal and enhancement at the pubic symphysis was thought to represent osteitis pubis. The patient’s symptoms resolved after one month of urethral catheter drainage, intravenous antibiotics, and anti-inflammatory therapy.

Chordomas are rare, slow-growing tumors arising from cellular remnants of the notochord. They account for 1-4% of primary malignant bone tumors and usually occur in the axial skeleton, most commonly the sacrum. Although typically locally recurrent, chordoma metastasis rates as high as 10-42% have been reported. While spread to multiple organ systems has been documented, metastatic disease to skeletal muscle is extremely rare. We present a case of extensive, multifocal skeletal muscle metastases developing in the setting of recurrent sacral chordoma. Our literature search found only one additional case of metastatic chordoma to a single skeletal muscle.

The purpose of this study was to determine the relative prevalence of the sclerosing variant of well-differentiated liposarcoma at one institution and to elucidate the CT and MRI characteristics of this subtype of well-differentiated liposarcoma.A retrospective computerized search was conducted to calculate the relative prevalence of the sclerosing variant of well-differentiated liposarcoma among all well-differentiated liposarcoma subtypes at one institution. The MRI and CT features of a total of 19 cases of pathologically proven sclerosing variant of well-differentiated liposarcoma were evaluated (seven identified from the study institution database and 12 cases contributed by other institutions).The cases of a total of 36 patients with well-differentiated liposarcoma were identified in the pathology database; six (17%) cases had evidence of dedifferentiation. Seven (19%) cases of sclerosing variant of well-differentiated liposarcoma were identified. Of these, three (43%) had evidence of dedifferentiation. On images, the sclerosing variant of well-differentiated liposarcoma typically presented as a large (average, 16.6 cm) well-circumscribed heterogeneous mass most commonly situated in the retroperitoneum (58%). Sixteen of the 19 tumors evaluated (84%) had predominantly well-circumscribed margins. Tumor composition ranged from predominantly fatty to entirely devoid of macroscopic fat; only three (16%) were composed of more than 75% fat. Variable amounts of nonlipomatous elements were identified in all cases. Enhancement of these elements was evident at CT or MRI in all 14 cases in which enhancement could be reliably assessed.The sclerosing variant of well-differentiated liposarcoma should be included in the differential diagnosis of any well-circumscribed lipomatous mass containing variable amounts of nonlipomatous elements, particularly when located in the retroperitoneum. Unlike other subtypes of well-differentiated liposarcoma, the sclerosing variant is less likely to be composed predominantly of fat and may be associated with an increased propensity for dedifferentiation.

This article discusses several benign tumors and proliferative processes of the synovium including giant cell tumor of the tendon sheath, pigmented villonodular synovitis, synovial chondromatosis, lipoma arborescens, and synovial hemangioma, lipoma, and fibroma. We review the clinical features and imaging characteristics of each entity, with a special focus on the unique imaging findings that can enable a confident diagnosis or a limited differential diagnosis.