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Background: Magnetic Resonance Imaging is the method of choice for the diagnostic work-up of soft tissue tumors. It is the modality of choice to evaluate such masses, because of its excellent soft tissue contrast. Aim of Study: To assess the efficacy of Diffusion weighted MRI in characterization of musculoskeletal soft tissue tumors. Patients and Methods: The current study enrolled 20 patients (11 female and 9 male) with musculoskeletal STTs with mean age was 41.08±11.54 year. The most frequent affected site with the swelling was the thigh (48%) followed by the arm (20%). Four (16%) patients suffered from leg swelling while three (12%) patients had shoulder swelling. Our results revealed that malignant musculoskeletal soft tissue masses had significantly lower ADC value in comparison to those with benign masses (0.70±0.09 vs. 1.58±0.52x10-3m2/s; p < 0.001). Results: Patients with malignant lesions had significantly lower ADC value in comparison to those with benign lesions (0.70±0.09 vs. 1.58±0.52 (103mm2/s). Myxoma had the highest ADC value that was 2.44 (103mm2/s) while sarcoma had lowest value that was 0.54±0.03 (103mm2/s). It was noticed that MRI had 100% sensitivity and 81.8% specificity for diagnosis of malignant musculoskeletal soft tissue masses with overall accuracy was 92% and area under curve was 0.91 at cut off value was

Introduction: Percutaneous ultrasound-guided core needle biopsy is a well-established method in the diagnosis of musculoskeletal tumors. It is unclear which factors contribute the most to a successful biopsy. The aim of the study was to determine the value of ultrasoundguided core needle biopsy of solid lesions in the musculoskeletal system using a 16-gauge needle. Material and methods: A retrospective analysis performed at a regional sarcoma center over one year included patients referred for ultrasound-guided biopsy of musculoskeletal soft tissue lesions. At least 6 months’ clinical and radiological follow-up, results from repeat or excisional biopsy, or interventional treatment, served as outcome reference. The biopsy procedure and yield were analyzed. The biopsy was classified as ‘diagnostic’ when a definitive diagnosis could be made on the first biopsy, and ‘accurate’ when only the malignant or benign nature of the tumor could be determined. Results: From 102 referrals for biopsy of soft tissue lesions in 2019, a total of 73 biopsies of solid lesions with a 16-gauge cutting needle were included (73 patients). There were 34 males and 39 females, with a mean age of 57.7 years. The overall proportion of diagnostic biopsies was 84%, for malignant lesions 88% and benign lesions 81%. The tumor could be classified as malignant or benign in 12 patients (16%) (accurate biopsy). It was possible to discriminate between malignant and benign lesions in each case. The majority of biopsied lesions were benign 64% (n = 47). Conclusion: The diagnostic value of ultrasound-guided percutaneous core needle biopsy of musculoskeletal soft tissue lesions performed with 16-gauge needle is good, with a high rate of diagnostic biopsies, both for benign and malignant lesions.

Musculoskeletal (MSK) image-guided oncologic intervention is an established field within radiology. Numerous studies have described its clinical benefits, safety, cost effectiveness, patient satisfaction, and improved quality of life, thereby establishing image-guided oncologic intervention as a preferred pathway in treating patients presenting with specific benign MSK tumors. But there is a paradigm shift on the horizon because these techniques may also support established pillars (surgery, systemic treatment, radiotherapy) in the treatment of malignant MSK tumors. Unlike benign tumors, where they are used as primary therapy lines with curative intent, such interventions can be selected for malignant tumors as adjuvant treatment in painful or unstable bone or soft tissue lesions or as more palliative therapy strategies. Using examples from our clinical practices, we elaborate on the benefits of applying a multidisciplinary approach (traditionally involving MSK radiologists, oncologists, orthopaedic surgeons, microbiologists, pathologists, physiotherapists, and pain management experts), ideally within a sarcoma treatment center to deliver a patient-specific therapy plan and illustrate methods to assess the benefits of this model of care.In this article, we review the current repertoire of ablation techniques, demonstrate why such procedures offer value-based alternatives to conventional treatments of specific tumors, and reflect on future directions. Additionally, we review the advantages and limitations of each technique and offer guidance to improve outcomes.

Treatment of soft tissue sarcomas (STS) should only be initiated once the diagnosis is fully established. Resection of tumors of unknown nature should be avoided. Nevertheless, specialized centers continue to face numbers of unplanned excisions (UPE) in STS.To compare oncologic and functional outcomes, number of surgeries, length of hospital stay and treatment costs of UPE versus planned excision (PE) in STS.A retrospective single tertiary center study was performed on 201 patients. Survival, local and distant recurrence rates were compared between PE (n = 137) and UPE (n = 64). In a subgroup analysis of 60 patients, functional outcome (MSTS and TESS scores), and socio-economic impact (number of surgeries, length of hospital stay and treatment costs) in "functional planned excision" (fPE) group (n = 30) and "functional unplanned excision" (fUPE) group (n = 29) were compared.There was no significant difference in oncological outcome between PE and UPE. In the subgroup analysis, we found a non-significant difference in functional outcome. Patients in the fUPE had significantly more surgeries (3.5 vs. 1.4; p 0.00001) and costs of their management was 64% higher than fPE (p = 0.048). Hospital stay was longer after fUPE but not statistically significant (18.3 days vs. 11.8 days; p = 0.13).Even though oncological and functional outcomes are comparable after PE and UPE of STS, the number of surgeries, length of hospital stay and treatment costs were higher in patients with UPE. Our data underscore the importance of specialized STS treatment centers including multidisciplinary management.

Studies have reported the association of the COL1A1 Sp1 binding site variant (rs1800012) with the risk of acute musculoskeletal soft tissue injuries. Interaction with the COL1A1 promoter variant (rs1107946) has also been proposed to modulate acute injury risk. Conversely, neither of these loci have been associated with chronic musculoskeletal soft tissue phenotypes. Therefore, the primary aim of this study involved characterizing these variants in a cohort of participants with chronic Achilles tendinopathy. Second, this study aimed to support the contribution of the rs1107946 and rs1800012 variants to the profile predisposing for acute musculoskeletal soft tissue injuries including Achilles tendon and anterior cruciate ligament (ACL) ruptures. A hypothesis-driven association study was conducted. In total, 295 control participants, 210 participants with clinically diagnosed Achilles tendinopathy, and 72 participants with Achilles tendon ruptures recruited independently from South Africa and the United Kingdom were genotyped for the prioritized variants. In addition, a cohort including 232 control participants and 234 participants with surgically diagnosed ACL ruptures was also analyzed. Although no associations were observed in the recruited cohorts, the rare rs1800012 TT genotype was associated with decreased ACL injury risk when the results from the current study were combined with that from previously published studies (P = .040, OR: 2.8, 95% CI: 1.0-11.0). In addition, the G-T (rs1107946-rs1800012) inferred haplotype was associated with decreased risk for Achilles tendon ruptures. These results support previous observations and reiterate the heterogeneity of musculoskeletal phenlotypes whereby certain markers may be common to the predisposing profiles while others may be unique.

Background In pediatric patients, soft tissue masses encompass a wide heterogeneous group of benign and malignant lesions. MRI is a powerful diagnostic tool in the workup of soft tissue tumors in children, and it helps in characterization of lesion and evaluation of the extent of the lesion. However, conventional MRI techniques are not specific in differentiating benign from malignant lesions. So to improve characterization of tumors, DWI was added to MRI techniques as it increases sensitivity and specificity by detecting the micro-diffusion changes of water into intra- and extracellular spaces. The aim of this work was to highlight the diagnostic value of DWI in detection and characterization of different musculoskeletal soft tissue masses in pediatrics. Results There was a statistically significant difference regarding the mean ADC value of benign and malignant masses (P value = 0.001*). The mean ADC value for all benign masses (n = 41) was 1.495 ± 0.55 SD × 10–3 mm2/s, while the mean ADC value for all malignant masses (n = 21) was 0.449 ± 0.27 SD × 10–3 mm2/s. The cutoff ADC value between benign and malignant masses was 0.88 × 10–3 mm2/s. This cutoff ADC value has sensitivity of 100.0%, specificity of 92.3%, PPV of 66.7%, NPV of 100.0% and diagnostic accuracy of 93.3%. Conclusion In pediatric patients, DWI is an innovative valuable noninvasive imaging technique for characterization of musculoskeletal soft tissue masses and discrimination between benign and malignant masses.

The lungs are the commonest site of metastasis for primary high-grade bone and soft tissue sarcoma, but current guidelines on the management of pulmonary nodules do not specifically cater for this group of patients. The current article reviews the literature from the past 20 years that has reported the CT features of pulmonary metastases in the setting of known primary bone and soft tissue sarcoma, with emphasis on osteosarcoma, chondrosarcoma, and trunk and extremity soft tissue sarcoma, the aim being to aid radiologists who report chest CT of musculoskeletal sarcoma patients in deciding which lesions should be considered metastatic, which lesions are indeterminate and require follow-up, and which lesions are of no concern.

Objective: To evaluate the diagnostic performance of standard diffusion-weighted imaging (DWI), intravoxel incoherent motion (IVIM), and diffusion kurtosis imaging (DKI), for differentiating benign and malignant soft tissue tumors (STTs). Materials and methods: A thorough search was carried out to identify suitable studies published up to September 2020. The quality of the studies involved was evaluated using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). The pooled sensitivity (SEN), specificity (SPE), and summary receiver operating characteristic (SROC) curve were calculated using bivariate mixed effects models. A subgroup analysis was also performed to explore the heterogeneity. Results: Eighteen studies investigating 1319 patients with musculoskeletal STTs (malignant, n=623; benign, n=696) were enrolled. Thirteen standard DWI studies using the apparent diffusion coefficient (ADC) showed that the pooled SEN and SPE of ADC were 0.80 (95% CI: 0.77-0.82) and 0.63 (95% CI: 0.60-0.67), respectively. The area under the curve (AUC) calculated from the SROC curve was 0.806. The subgroup analysis indicated that the percentage of myxoid malignant tumors, magnet strength, study design, and ROI placement were significant factors affecting heterogeneity. Four IVIM studies showed that the AUCs calculated from the SROC curves of the parameters ADC and D were 0.859 and 0.874, respectively. The AUCs for the IVIM parameters pseudo diffusion coefficient (D*) and perfusion fraction (f) calculated from the SROC curve were 0.736 and 0.573, respectively. Two DKI studies showed that the AUCs of the DKI parameter mean kurtosis (MK) were 0.97 and 0.89, respectively. Conclusion: The DWI-derived ADC value and the IVIM DWI-derived D value might be accurate tools for discriminating musculoskeletal STTs, especially for non-myxoid SSTs, using more than two b values, with maximal b value ranging from 600 to 800 s/mm2, additionally, a high-field strength (3.0 T) optimizes the diagnostic performance.

Physiotherapy is one of the preferred treatment options in patients with dentomaxillofacial region painful musculoskeletal problems. In initial diagnosis and posttreatment of follow-up, musculoskeletal soft tissue imaging is necessary to assess the morphologic and metabolic status of soft tissues. In recent years, elastography has gradually been used for examining musculoskeletal tissues. There are several elastography techniques in clinical practice; sonoelastography and shear-wave elastography are the most common techniques to evaluate soft tissue elasticity. However, shear-wave elastography is considered to be more objective, quantitative, and reproducible than compression sonoelastography with increasing applications to the musculoskeletal system. Musculoskeletal soft tissues have different characteristics which may affect the evaluation procedures. This chapter describes the basic features of elastography and analyzes the factors that can influence measurements of soft tissue, limitations of techniques, and provides an overview of potential clinical applications.

Objectives: To determine the differential diagnosis of musculoskeletal soft tissue masses in children referred to a specialist musculoskeletal oncology unit. Methods: All children (0–18 y) referred to a specialist musculoskeletal oncology unit over a 20-month period (September 2018–May 2020) were retrospectively reviewed. Demographic data and referral diagnoses were obtained from the electronic patient notes. MRI findings and histopathological results were recorded. The comparison of non-neoplastic, benign neoplastic and malignant diagnoses at the point of referral and final diagnosis was determined. Results: 116 patients were included, 60 (51.7%) males and 56 (48.3%) females with mean age of 10.6 years (3 months–18 years). 69 (59.5%) patients were referred with a suspected sarcoma, 29 (25.0%) with a suspected benign tumour and 18 (15.5%) with a non-neoplastic lesion. A diagnosis was achieved by histological assessment in 61 (52.6%) cases, microbiological assessment in 3 (2.6%) or clinical and imaging assessment in 52 (44.8%). 67 (57.8%) cases had non-neoplastic pathology, 39 (33.6%) a benign tumour, 4 (3.4%) an intermediate-grade tumour, 6 (5.2%) a malignant tumour. Conclusions: Although over half of children referred to a specialist musculoskeletal oncology unit were suspected of having a soft tissue sarcoma at referral, only 5.2% were diagnosed with a malignant tumour. Advances in knowledge: Approximately, 6 of 69 (8.7%) children referred to a specialist musculoskeletal oncology unit with a suspected soft tissue sarcoma will have a malignant lesion. Most paediatric soft tissue masses are non-neoplastic, the commonest diagnosis being a vascular malformation.

Objective: To determine the suitability of primary excision of small indeterminate deep soft tissue masses presenting to a tertiary musculoskeletal oncology service. Methods and materials: Review of all patients referred to a specialist musculoskeletal oncology service over a 20-month period with a deep indeterminate soft tissue mass by non-contrast MRI criteria that was recommended for primary surgical excision due to relatively small size (Results: 85 patients were included, mean lesion size being 12 mm (range 5–29 mm). Primary surgical resection had been undertaken in 69 cases (81.2%) by the conclusion of data collection, 36 males and 33 females with mean age of 45.6 years (range 11–80 years). Of these, 11 cases (15.9%) were non-neoplastic, 53 (76.8%) were benign, 1 (1.4%) was intermediate grade, while 4 (5.8%) were malignant including 3 synovial sarcomas. Two of these were treated with re-excision of the tumour bed showing no residual disease, with no evidence of local recurrence at a mean of 10.7 months post-excision. Conclusion: Primary surgical excision of small deep soft tissue masses that are indeterminate by non-contrast MRI criteria is considered a safe procedure when undertaken in a specialist musculoskeletal oncology service, with only 4 of 69 cases (5.8%) being malignant. Advances in knowledge: Small indeterminate deep soft tissue masses can safely be treated with primary excision in the setting of a specialist musculoskeletal oncology service.

Background To explore the feasibility to identify malignant musculoskeletal soft tissue tumors using real-time shear wave elastography (rtSWE). Methods One hundred fifteen musculoskeletal soft tissue tumors in 92 consecutive patients were examined using both conventional ultrasonography (US) and rtSWE. For each patient, the rtSWE parameters including maximum elasticity (Emax), mean elasticity (Emean), minimum elasticity (Emin), standard deviation of the elasticity (Esd), and rtSWE image pattern were obtained. Eighty-one histopathologically confirmed tumors from 73 patients were subjected to analysis. Results The 81 lesions included in the study were histopathologically classified as malignant (n = 21) or benign (n = 60). The statistically significant differences between benign and malignant lesions were found in conventional US characters including size, depth, margin, echogenicity, mass texture, and power Doppler signal. Meanwhile, the significant differences were also found in quantitative rtSWE findings including Emax, Emean, Emin, and Esd values and in qualitative rtSWE parameter named rtSWE image pattern. Multivariate analysis showed that infiltrative margin (OR, 4.470), and size (OR, 1.046) were independent predictors for malignancy in US findings, while Esd value (OR, 9.047) was independent predictors for malignancy in quantitative rtSWE parameters. Areas under the ROC curve (Azs) for US features, Esd value, and rtSWE image pattern were 0.851, 0.795, and 0.792, respectively. Conclusions Conventional US and quantitative and qualitative rtSWE parameters are useful for malignancy prediction of musculoskeletal soft tissue tumors. rtSWE can be used to supplement conventional US to diagnose musculoskeletal soft tissue tumors.

Neoplastic musculoskeletal lesions are heterogeneous tumors with variable outcomes that require a precise diagnosis and delivery of optimal, specific treatment. Advanced MR imaging techniques can help differentiate and characterize musculoskeletal soft tissue tumors and are the method of choice for detection, evaluation, local staging, and surgical planning. MR imaging-ultrasound fusion is the process of combining relevant information from 2 methods into a single image that is more informative than the images obtained separately. This article assesses the potential of fusing real-time ultrasound spatial registration with previously acquired musculoskeletal MR imaging to guide tumor tissue biopsies and procedures.

Objective: To assess the ability of DWI & numerical ADC values associated with routine MRI in classification of different musculoskeletal soft tissue masses. Patient & method: 45 patients (32 females and 13 males) with known or clinically suspected to have musculoskeletal soft tissue masses were included. Their age ranging from (9–72) years, they all subjected to conventional MRI, DWI and ADC values were calculated, The diagnosis was confirmed by histologic biopsy. Results: Benign neoplasms (except for lipomas) showed values of ADC above 1.275 × 10−3 mm2/s while malignant soft tissue tumors (except for high-grade myxofibrosarcoma) have ADC values below 1.1 × 10−3 mm2/s. Mean ADC values for benign and malignant soft tissue tumors were 1.53 ± 0.91 mm2/s and 0.84 ± 0.33 mm2/s respectively with cutoff value 1.235 mm2/s showing sensitivity, specificity & accuracy 73%, 91.7% & 80.3% respectively. Tru cut biopsy done in (28) patients (8 benign & 20 malignant masses), frozen sections confirmed diagnosis of other 10 benign masses and reconfirmed diagnosis of the previously biopsied 20 malignant masses, the last 7 patients couldn't be biopsied & were diagnosed from patient medical profile at our institute. Conclusion: Addition of DWI &quantitative ADC mapping to routine MR examination is advised for evaluation of soft tissue tumors especially in the inconclusive cases. Keywords: Diffusion MRI, Soft tissue masses

Purpose: To assess the utility of diffusion-weighted (DW) images and magnetic resonance imaging (MRI) in the detection and characterization of musculoskeletal soft tissue tumours (STTs) and in the determination of whether these tumours are benign or malignant. Patients and methods: A prospective study was performed between March 2016 and March 2017 that included all patients referred to the radio-diagnosis department for evaluation of musculoskeletal STTs. Contrast-enhanced MRI and DW images were performed for all included patients, and diagnoses were confirmed by biopsy and histopathological examination. Results: The apparent diffusion coefficient (ADC) of benign STTs was significantly higher than that of malignant (mean ± SD, −1.43 ± 0.56 × 10−3 mm2/s versus 0.74 ± 0.18 × 10−3 mm2/s, respectively (P

Background: magnetic resonance imaging (MRI) has an important role in characterization of soft tissue tumors, yet, it lacks specificity for differentiation between the benign and malignant lesions. Aim of the Work: this study aimed to evaluate the ability of DW MRI in detection and characterization of the musculoskeletal soft tissue tumors. Patients and methods: this prospective study included 30 patients (20 females and 10 males) referred to MRI unit Ain shams University Hospital for MRI evaluation of musculoskeletal soft tissue tumors. Results: from 30 cases, 12 cases were benign (40%), 18 cases malignant (60%). From 12 cases of the benign, 8 cases were ≤ 40 years and 4 cases were > 40. From 18 cases of the malignant, 7 cases were ≤ 40 and 11 cases > 40. Ranging of ADC value of benign tumors (1.72-2.58); mean ADC (2.21 ´ 10-3 mm2/sec). Ranging of ADC value of malignant tumors was 0.52-1.82. Mean ADC value was 0.90 ´ 10-3 mm2/sec. Cut-off ADC value ≤ 1.14 less than 1.14 was benign and more than 1.14 was malignant; sensitivity 94.4% and specificity 91.7%. Conclusion: DWI with ADC mapping and measurement of ADC value proved to be a valuable non –invasive tool in differentiating between benign and malignant musculoskeletal soft tissue tumors. Recommendations: a larger population for future studies is needed. Thus, histopathologic work up is required for reliable characterization of soft tissue tumors (4).

Musculoskeletal soft tissue infections are not uncommonly encountered in both the clinic and Emergency Department setting. The clinical diagnosis is not always evident as these infections can have variable presentations depending on the duration and depth of disease extension through the soft-tissue layers. Imaging often plays an important role in diagnosing the infection, defining the extent of involvement, directing tissue sampling, and in monitoring treatment response. After initial radiographs, ultrasound (US) is often the next modality utilized to evaluate patients with suspected soft tissue infections given its low cost, availability, portability, and potential for real-time guidance of fluid aspiration. The widespread use of cross-sectional imaging with magnetic resonance imaging (MRI) and computed tomography (CT) has greatly increased the radiological diagnosis in conditions where US may be limited. In addition, CT and MRI allow a thorough evaluation of disease extension, including assessment of joint spaces, tendons, and osseous changes indicative of bone involvement. This review will focus on the radiological findings of soft tissue infections on US, CT, and MRI.

Soft-tissue sarcomas (STS) are a rare subtype of soft-tissue mass and are frequently misinterpreted as benign lesions. Magnetic resonance imaging (MRI) is the primary recommended type of diagnostics. To assess the quality of primary radiology reports, we investigated whether recommended MRI report elements were included in compliance with European Society of Musculoskeletal Radiology (ESSR) guidelines. A total of 1107 patients were evaluated retrospectively, and 126 radiological reports on patients with malignant STS were assessed for ESSR quality criteria. One or more required sequences or planes were missing in 67% of the reports. In all 126 cases, the report recognized the mass as anomalous (100%). Sixty-eight percent of the reports mentioned signs of malignancy. The majority of reports (n = 109, 87%) articulated a suspected diagnosis, 32 of which showed a mismatch with the final diagnosis (25%). Thirty-two percent of the reports had a misinterpretation of the masses as benign. Benign misinterpretations were more common in masses smaller than 5 cm (65% vs. 27%). Thirty percent of the reports suggested tissue biopsy and 6% recommended referral to a sarcoma center. MRI reports showed frequent deviations from ESSR guidelines, and protocol guidelines were not routinely met. Deviations from standard protocol and reporting guidelines could put patients at risk for inadequate therapy.

Background: Clinical practice guidelines (CPGs) are published by several sports medicine institutions. A systematic evaluation can help identify the highest quality CPGs for clinical use and identify any deficiencies that remain. Purpose: To identify and appraise CPGs relevant to clinical sports medicine professionals. Study Design: Systematic review. Methods: Predetermined selection criteria were utilized by 2 reviewers who independently identified published CPGs before January 1, 2014. CPGs were excluded if they focused on injured workers, radiological criteria, medical pathology, or the axial skeleton (back/neck). The remaining guidelines were scored by 6 reviewers with different clinical backgrounds using the Appraisal of Guidelines for Research and Evaluation II (AGREE II). Scores lower than 50% indicated deficiency. Scores were also stratified by the publishing institution and anatomic location and compared using Kruskal-Wallis tests. The Spearman correlation coefficient was used to assess the range of interobserver agreement between the evaluators. Results: Seventeen CPGs met the inclusion criteria. The majority of guidelines pertained to the knee, ankle, or shoulder. Interobserver agreement was strong ( r = 0.548-0.740), and mean total scores between nonsurgical (107.8) and surgical evaluators (109.3) were not statistically different. Overall guideline quality was variable but not deficient for 16 of 17 guidelines (>50%), except regarding clinical “applicability” and “editorial independence.” No difference was found between CPGs of the knee, shoulder, foot/ankle, or chronic conditions. However, CPG publishing institutions had significantly different scores; the American Academy of Orthopaedic Surgeons (AAOS) guidelines scored significantly higher (141.4) than the total mean score (108.0). Conclusion: The overall quality of sports medicine CPGs was variable but generally not deficient, except regarding applicability and editorial independence. Bias through poor editorial independence is a concern. To improve future guideline quality, authors should pay particular attention to these areas and use existing highest quality guidelines, or the AGREE II instrument, as templates. CPGs dedicated to anatomic areas other than the knee, ankle, and shoulder are needed.

The majority of peripheral musculoskeletal soft tissue masses encountered in routine clinical practice are benign and associated with an excellent prognosis, whereas a small proportion of soft tissue masses are malignant and are associated with higher morbidity and mortality. Owing to the excellent tissue contrast resolution provided, magnetic resonance imaging (MRI) is a primary modality for the diagnostic evaluation of soft tissue masses, particularly for defining the anatomic extent. MRI is also useful for the characterization of soft tissue masses; however, after the exclusion of cysts and lipomas, it is challenging to accurately categorize neoplastic lesions as benign or malignant with conventional anatomic MRI. Quantitative MRI biomarkers obtained with nonconventional pulse sequences are becoming increasingly available, and can improve the accuracy of determining the character of soft tissue masses. In this article we discuss established qualitative and emerging quantitative MRI-based biomarkers available with dynamic contrast-enhanced MRI, diffusion-weighted imaging, and MR spectroscopy and their utility for the characterization of untreated soft tissue masses. Level of Evidence: 5 Technical Efficacy Stage: 5 J. Magn. Reson. Imaging 2019;50:11-27.

The lesions of the soft tissues are rare and extremely heterogeneous; even if the surgical treatment is usually the standard therapy, the role of the interventional radiology (IR) in this field is growing up for multiple reasons. First, because the imaging alone usually is not able to ensure a definitive diagnosis, IR has a basic role in the staging: the percutaneous biopsy is infact an irreplaceable step. Moreover, biopsy is necessary not only for histologic evaluations but also for the biochemical and molecular studies. Furthermore, the proved safety and effectiveness of IR in a multiple oncologial applications prompt a wider use also in this field.

To determine the effectiveness of ultrasonographically (US) guided core needle biopsy (CNB) for diagnosis of small musculoskeletal soft-tissue lesions by demonstrating the noninferiority of the diagnostic yield with US-guided CNB in lesions measuring 2 cm or smaller to that for lesions larger than 2 cm.This retrospective study was institutional review board approved, and the requirement to obtain informed consent was waived. Five hundred US-guided CNBs performed for diagnosis of musculoskeletal soft-tissue lesions were included. Results of US-guided CNBs were divided into four categories, and the diagnostic yields were calculated on the basis of lesion size. A one-sided 97.5% confidence interval was calculated to determine the mean difference in diagnostic yields to test for noninferiority. In addition, the diagnostic yield with US-guided CNBs for lesions 1 cm or smaller was compared with that for lesions larger than 1 cm.A total of 500 technically successful US-guided CNBs in 494 patients with musculoskeletal soft-tissue lesions who underwent subsequent surgical excision or at least 6 months of follow-up were included. The diagnostic yields with US-guided CNB were 87% for lesions larger than 2 cm and 88% for lesions 2 cm or smaller. The lower bound of the confidence interval was -0.07, thus the noninferiority of the diagnostic yield with CNB for lesions 2 cm or smaller to that for lesions larger than 2 cm was shown. On the other hand, the diagnostic yield with US-guided CNB for lesions 1 cm or smaller was inferior to that for lesions larger than 1 cm.US-guided CNB of musculoskeletal soft-tissue lesions is effective for diagnosis and decision making, even in lesions measuring 2 cm or smaller. However, when a lesion is 1 cm or smaller, US-guided CNB is more frequently insufficient for histopathologic diagnosis.

MRI plays a central role in the assessment of pediatric musculoskeletal soft tissue tumors. Although these neoplasms may initially be evaluated on other modalities, such as sonography, MRI is essential for accurately determining the extent of disease. Traditionally, MRI has been performed with sequences that provide excellent anatomic detail, with T1-weighted, fluid-sensitive, and static postcontrast T1-weighted sequences. However, with the introduction of noncontrast sequences such as diffusion-weighted imaging and magnetic resonance spectroscopy to the arsenal of available MRI techniques, functional and metabolic features of a neoplasm can now be examined noninvasively. These more recent MRI methods offer information for lesion characterization, the assessment of treatment response, and the distinction of postoperative scar from recurrence. Dynamic contrast-enhanced perfusion imaging is another useful functional technique that can be acquired before conventional static postcontrast imaging, without requiring additional contrast material. This review presents recent advances in MRI methodology that enable a comprehensive clinical assessment of musculoskeletal tumors in the pediatric population. The roles and challenges of combining anatomic, functional, and metabolic MRI sequences will be discussed as they relate to newly discovered soft tissue tumors in children.

Background and objective The prevention, diagnosis, and management of non-contact musculoskeletal soft tissue injuries (NCMSTIs) related to participation in sports are key components of sport and exercise medicine. Epidemiological data have demonstrated the existence of interindividual differences in the severity of NCMSTIs, indicating that these injuries occur as a consequence of both extrinsic and intrinsic factors, including genetic variations. Subjects and methods We have collected data on NCMSTIs suffered by 73 elite players of White, black African and Hispanic ethnicity of European football over the course of three consecutive seasons. We have also examined eight single nucleotide polymorphisms (SNPs) in genes related to tissue recovery and tissue repair in blood drawn from the players and correlated our findings with type and severity of injuries in each ethnic group. Results The frequency of the SNPs varied among the three ethnic sub-groups ( p p = 0.001) and between tendinous injuries and ELN ( p = 0.05) and IGF2 ( p = 0.05). Among Hispanics, there was a significant relation between muscle injuries and ELN ( p = 0.032) and IGF2 ( p = 0.016). Conclusions Interracial genotypic differences may be important in the study of NCMSTIs. A genetic profile based on SNPs may be useful tool to describe each individual's injuribility risk and provide specific treatment and preventive care for football players.

Introduction Musculoskeletal Soft Tissue Tumours (STT) are frequent heterogeneous lesions. Guidelines consider a mass larger than 5 cm and deep with respect to the deep fascia potentially malignant. Contrast Enhanced Ultrasound (CEUS) can detect both vascularity and tumour neoangiogenesis. We hypothesised that perfusion patterns and vascularisation time could improve the accuracy of CEUS in discriminating malignant tumours from benign lesions. Materials and methods 216 STT were studied: 40% benign lesions, 60% malignant tumours, 56% in the lower limbs. Seven CEUS perfusion patterns and three types of vascularisation (arterial-venous uptake, absence of uptake) were applied. Accuracy was evaluated by comparing imaging with the histological diagnosis. Univariate and multivariate analysis, Chi-square test and t-test for independent variables were applied; significance was set at p Results CEUS pattern 6 (inhomogeneous perfusion), arterial uptake and location in the lower limb were associated with high risk of malignancy. CEUS pattern has PPV 77%, rapidity of vascularisation PPV 69%; location in the limbs is the most sensitive indicator, but NPV 52%, PPV 65%. The combination of CEUS-pattern and vascularisation has 74% PPV, 60% NPV, 70% sensitivity. No correlation with size and location in relation to the deep fascia was found. Conclusion US with CEUS qualitative analysis could be an accurate technique to identify potentially malignant STT, for which second line imaging and biopsy are indicated in Referral Centers. Intense inhomogeneous enhancement with avascular areas and rapid vascularisation time could be useful in discriminating benign from malignant SST, overall when the lower limbs are involved.

The present study describes the use of the "moving-shot" technique for successful radiofrequency ablation (RFA) of malignant musculoskeletal soft-tissue tumors. Ultrasonography-guided RFA was performed in 6 malignant soft-tissue tumors in 5 patients. Short-term follow-up after RFA (8-27 weeks) showed that complete necrosis was achieved in all lesions, and 5 lesions (83%) decreased in size. Discomfort caused by the tumors decreased subjectively in all patients after ablation. Our results indicate that ultrasonography-guided RFA using the moving-shot technique can be an effective treatment option for locoregional control of malignant soft-tissue tumors. Long-term follow-up studies with a larger number of patients are necessary.

OBJECTIVE. The objective of our study was to evaluate the diagnostic accuracy of ultrasound in assessing musculoskeletal soft-tissue tumors superficial to the investing fascia. MATERIALS AND METHODS. Seven hundred fourteen superficial soft-tissue tumors evaluated with ultrasound by two musculoskeletal radiologists were retrospectively reviewed. In all ultrasound reports, the reporting radiologists provided one, two, or three diagnoses depending on their perceived level of diagnostic certainty. Two hundred forty-seven tumors had subsequent histologic correlation, thus allowing the accuracy of the ultrasound diagnosis to be determined. Images of the lesions with a discordant ultrasound diagnosis and histologic diagnosis were reviewed, and the ultrasound features were further classified as concordant with the known histologic diagnosis, concordant with the known histologic diagnosis with atypical features present, or discordant with the known histologic diagnosis. Four hundred sixty-seven tumors without path...

Recognition of a soft tissue tumor on imaging, differentiation from a non-neoplastic soft tissue mass, and distinguishing benign from malignant soft tissue neoplasms are critical radiological skills yet prove to be pitfalls for many. Recognition of the characteristic imaging appearances of some of these conditions is crucial, and several of these are illustrated and described in this chapter. Appreciating the nonspecific nature of the imaging appearances of the remainder while ensuring that “nonspecific” means “could be malignant” to one’s clinical colleagues is the most important message of this chapter.

This paper provides a literature review of the use of magnetic resonance imaging in monitoring the treatment response of soft tissue sarcomas (STS). The basic classification and physiology of the soft tissue tumor is introduced. Then, the major treatment options for STS are summarized with brief coverage of possible responses and grading systems. Four major branches of MR imaging techniques are covered, including conventional T1- and T2-weighted imaging, contrast-enhanced MR imaging, MR diffusion and perfusion imaging, and MR spectroscopy, with a focus on the tumor microenvironment. Although this literature survey focuses on recent clinical developments using these MR techniques, research venues in pre-clinical studies, as well as in potential applications other than soft tissue sarcomas, are also included when comparable and/or mutually supporting. Examples from other less-discussed MR imaging modalities are also briefly covered, not only to complement but also to expand the scope and depth of information for various kinds of lesions.

Increased and decreased joint range of motion (ROM) are modifiable risk factors for musculoskeletal soft-tissue injuries. Certain heritable disorders of connective tissue, which have a unifying symptom of joint hypermobility, are caused by mutations within the COL5A1 gene. Furthermore, the COL5A1 BstUI restriction fragment length polymorphism (RFLP) sequence variant is associated with ROM measurements in a mixed injured/uninjured cohort. The association between COL5A1 BstUI RFLP and sit and reach (SR) ROM in an apparently healthy and physically active cohort was investigated. The SR test was performed on 325 white subjects (204 males). Subjects were also genotyped for the BstUI RFLP (C/T) within the 3′-untranslated region of the COL5A1 gene. The COL5A1 BstUI RFLP genotype was associated with SR ROM in older (≥35 years) subjects (TT: 225 ± 96 mm, TC: 245 ± 100 mm, CC: 32 ± 108 mm, N=96, P=0.017). Age and COL5A1 BstUI genotype interacted significantly for SR ROM. Sex and COL5A1 genotype accounted for 22.8% of the variance in SR ROM in the older group. The COL5A1 BstUI RFLP is associated with SR ROM, particularly with increasing age and is an important contributing factor to ROM variation, particularly in older, apparently healthy and physically active individuals.

High resolution ultrasound (HR-US) including color Doppler ultrasound (CD-US), power Doppler ultrasound (PD-US), and spectral wave analysis (SWA), is a broadly available, non-invasive and relatively low-cost modality without ionizing radiation. It is increasingly used for initial assessment of an ambiguous musculoskeletal soft-tissue lesion and for sonographically guided core biopsy. The aim of this review is to provide sonographic findings of the most frequent benign and malign soft-tissue lesions. By this essay, we can show that combined with clinical features, with information on tumor-localization and patient age, many musculoskeletal lesions may be successfully characterized by HR-US. In contrast, a mere morphologic assignment of some fibrous tumors and malignant lesions remains often impossible; however, certain CD-US signs such as anarchic vascular architecture or arteriovenous shunting may be very helpful indicators for malignancy. HR-US offers a simple, quick, and reliable first-line examination of musculoskeletal soft-tissue lesions and may have an important role in the diagnostic work-up followed by magnetic resonance or multimodality imaging and guided core biopsy.

This article describes the sonographic appearance of a variety of soft tissue masses. The authors review the current indications of musculoskeletal sonography as a screening and diagnostic imaging modality and its therapeutic role in the management of soft tissue masses.

Soft tissue masses have a varied presentation. Though all masses cannot be optimally imaged on USG, its easy availability, real-time capability, and cost-effectiveness, as well as the freedom it provides to examine in any direction, make it an automatic choice as a first-line modality. Though Doppler is an exciting modality, it has its limitations and is not always rewarding. USG is more useful for superficially located masses. The role of USG is to provide information about the extent of the mass, its nature, and its relationship to the surrounding structures. One important aim is to differentiate between a pseudotumor and a true mass lesion. Doppler can provide additional information in selected cases. USG can play a pivotal role in guiding a needle for obtaining a sample for tissue diagnosis. Benign lesions are more common than malignant ones, in day-to-day practice. As with any other musculoskeletal examination, technical expertise and a sound knowledge of musculoskeletal anatomy are important.

Musculoskeletal diagnostic ultrasound imaging (MSK-DUSI) has been growing outside the traditional radiology speciality. Increased use of this technology has been reported in several healthcare settings, however an apparent gap in the knowledge of the accuracy of this diagnostic technology indicated a review was warranted. We undertook a structured review of the literature to assess the accuracy of MSK-DUSI for the diagnosis of musculoskeletal soft tissue pathology of the extremities. An electronic search of the National Library of Medicine’s PubMed database (1972 to mid-2014) was conducted. All relevant systematic reviews of diagnostic studies, all diagnostic studies published after the date of the latest systematic reviews and relevant diagnostic studies outside the scope the systematic reviews that directly compared the accuracy of MSK-DUSI (the index test) to an appropriate reference standard for the target condition were included. A fundamental appraisal of the methodological quality of studies was completed. The individual sensitivity, specificity and likelihood ratio data were extracted and entered into diagnostic accuracy tables. A total of 207 individual studies were included. The results show that MSK-DUSI has acceptable diagnostic accuracy for a wide spectrum of musculoskeletal conditions of the extremities. However, there is a lack of high quality prospective experimental studies in this area and as such clinicians should interpret the results with some caution due to the potential for overestimation of diagnostic accuracy. Electronic supplementary material The online version of this article (doi:10.1186/s12998-015-0076-5) contains supplementary material, which is available to authorized users.

Solitary fibrous tumors (SFTs) are rare mesenchymal neoplasms that can be benign or malignant. SFTs have been most often documented in the pleura. Recently, involvement of extrapleural sites such as the abdomen, musculoskeletal soft tissue, upper respiratory tract, mediastinum, and head and neck were reported. Less than 15 cases of SFT of the breast have been reported. Here, we report a case of a pathologically proven SFT of the breast and review the literature on the radiologic findings. US imaging showed an oval, well-circumscribed, hypoechoic solid mass. A solitary fibrous tumor of the breast is a very rare lesion.

AIM: To investigate whether analysing vascularity of soft-tissue tumours on ultrasound assists differentiating benign from malignant tumours. MATERIALS AND METHODS: One hundred and forty-eight vascular soft-tissue tumours in 148 patients (88 males, mean age 45.6 years) were studied. Final diagnosis was established histologically in 95 (64%) of cases. For each tumour, three-colour Doppler imaging features (vascularity, vascular density, vascular organization) and 13 pulsed Doppler (spectral analysis) parameters were assessed. Data analysis was performed to isolate optimal discriminatory criteria for differentiating benign from malignant tumours. RESULTS: Significantly more benign soft-tissue tumours had an organized vascular pattern on colour Doppler imaging. If the vascular pattern is organized, this is a good indicator of tumour benignity. However, this pattern was apparent in less then one-third of the soft-tissue tumours. Benign tumours also had significantly higher minimum end diastolic velocity (EDVmin) and lower mean ratio of resistive index (RImean) than malignant soft-tissue tumours, though considerable overlap existed between the two groups. CONCLUSION: Colour Doppler imaging analysis of soft-tissue tumours is of limited value when differentiating benign from malignant tumours. If an organized vascular pattern is present, the tumour is more likely to be benign. Flow characteristics were not specific enough to be applicable in clinical practice.

This chapter explores the current and future clinical applications of dual energy computer tomography (DECT) in the imaging of musculoskeletal soft tissue and bone tumors. The high stakes involved with musculoskeletal tumor imaging can be daunting. Missed diagnosis or misdiagnosis can lead to unnecessary investigations, biopsies, or surgeries. DECT is a promising new problem-solving tool in the armamentarium of imaging modalities available to the musculoskeletal radiologist in formulating a provisional diagnosis, determining prognosis, and contributing to a multidisciplinary treatment plan.

OBJECTIVE. The purpose of this article is to review the appropriate use of ultrasound in the workup of soft-tissue masses of the extremities. The normal sonographic appearance of superficial soft tissues, the importance of proper technique in image acquisition, and the characteristic sonographic appearance of certain masses and potential pitfalls are discussed. CONCLUSION. Ultrasound is increasingly being used for the initial evaluation of soft-tissue masses of the extremities. Certain clinical and imaging findings allow diagnosis of selected soft-tissue masses; however, most imaging findings are nonspecific, and further evaluation is necessary. The many potential pitfalls can lead to adverse patient outcomes.

Melioidosis is an infectious disease that can present with multiple foci of disease involvement. Assessment of disease extent can be difficult, especially in musculoskeletal, visceral and soft tissue infection. This study examined the usefulness of white cell scans in this condition. 99mTc stannous colloid white cell scanning was performed in 21 patients with culture-proven melioidosis. Scan results were compared with clinical assessment and correlated with other forms of imaging. White cell scans demonstrated all but one of the clinically apparent sites of musculoskeletal, visceral and other soft tissue infection. Unsuspected disseminated soft tissue lesions were seen in two patients, including femoral node uptake in both, and these patients subsequently presented with relapsing musculoskeletal disease. Unsuspected musculoskeletal disease was found in one patient. Clinically suspected musculoskeletal disease was accurately excluded by white cell scan in another patient. The results of white cell scanning were also examined in disease of other viscera. Renal and prostatic disease were visualized. Unsuspected parotid involvement was found in two patients. Only one of two spinal lesions was visualized. Pulmonary disease was not necessarily associated with abnormal uptake. White cell scanning is a quick and effective way of assessing the extent of musculoskeletal, visceral and soft tissue disease in melioidosis.

Published studies of sarcomas using 31P MRS suffer from technical limitations that include absence of localization to regions of interest, resulting in heavy contamination with signals from muscle, and poor resolution. This review has shown that, in spite of their limitations, many of these studies provide important leads to indicate the directions that need to be taken to further develop clinical and biologic uses of MRS. The uniqueness of the metabolic information available in vivo in a noninvasive manner using MRS provides a major stimulus to pursue these directions. In particular, the potential of 31P MRS to predict treatment sensitivity and resistance in individual cases could lead to a very cost-beneficial clinical use of this procedure. 1H-decoupling and NOE-enhancement, implemented in conjunction with dual-tuned surface coils and accurate localization of 31P MR spectra to regions of interest in three dimensions using CSI, have enabled us to overcome the major technical limitations mentioned earlier, broaden the scope of 31P MRS investigations, and obtain more information about the in vivo metabolic characteristics of soft-tissue sarcomas than has heretofore been available. Our approach, which has been fully implemented in a clinical imager, provides a good technical basis from which to examine potential clinical uses of 31P MRS. In particular, we can now rigorously test the hypotheses, derived from preliminary studies in the literature, that initial metabolic features or early treatment-induced changes in PME predict sensitivity of a sarcoma to that particular treatment. To this end, we at Fox Chase Cancer Center, along with investigators at Duke University, the Institute of Cancer Research/Royal Marsden Hospital, Johns Hopkins University, Memorial Sloan-Kettering Cancer Center, St. Georges Hospital Medical School, the University of California at San Francisco, and Wayne State University have initiated an NCI-sponsored cooperative trial to examine the role of 31P MRS in the clinical management of soft-tissue sarcomas and other selected cancers.

Intraoperative ultrasonography is a useful tool for the detection and extirpation of liver metastases, breast masses, and melanoma. However, the efficacy of this technology in intraoperative localization and resection of small soft tissue tumors has not been addressed. The purpose of this study is to report on the efficacy of intraoperative ultrasound assistance in excising impalpable musculoskeletal soft tissue tumors. Twenty-two soft tissue tumors Intraoperative ultrasound can be used as an efficient tool to localize and treat impalpable small soft tissue tumors.

The efficacy of gadopentetate dimeglumine (Gd-DTPA) enhanced magnetic resonance (MR) imaging in the diagnosis and differentiation of soft-tissue, neoplastic and non-neoplastic lesion has not been well established. Thirty patients with soft tissue masses (18 neoplastic and 12 non-neoplastic) were studied, using MR imaging with and without administration of Gd-DTPA. Gd-DTPA proved helpful in characterisation of several entities, including differentiation of solid mass from proteinaceous cyst, demonstration of tumour nodules within haemorrhagic or necrotic masses, and delineation of tumour adjacent to oedema. The use of Gd-DTPA may provide additional information for tissue specificity and, in complicated cases, Gd-DTPA may also provide essential information that cannot be obtained using other methods. We recommend the use of contrast enhanced MR as an adjunct to conventional MR imaging in the initial assessment of musculoskeletal soft tissue masses. However, T2-weighted images show better tissue contrast of the lesions, and are equal to contrast enhanced images in delineation of tumour margins. Non-contrast enhanced images are, therefore, probably adequate for the delineation of lesions for surgical planning when a diagnosis has already been made.