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Soft-tissue sarcomas are a diverse group of rare mesenchymal malignancies accounting for only 1% of all solid adult malignancies. These have been categorized in 12 broad groups by the World Health Organization (WHO) with their recent update in 2013. Majority of them lack specific imaging features serving as imaging conundrums for a radiologist. These are often large masses at presentation as they are asymptomatic or cause vague clinical symptoms. These tumors are challenging for surgeons as well as they find it difficult to achieve complete resection because of complex intra-abdominal anatomy and their close relationship with critical structures. Often, a multidisciplinary approach is required to decide on the most appropriate management for these complex cases so as to provide optimal patient care. Knowledge of the WHO classification, pathologic features and available treatment options will help the radiologist make a meaningful contribution in multidisciplinary discussions of such cases and overall patient care. Liposarcoma (well-differentiated and dedifferentiated liposarcomas), leiomyosarcoma, and gastrointestinal stromal tumor are the 3 most common primary intra-abdominal sarcomas. In part 1 of this article, general features of soft tissue sarcomas and some of the common tumors from WHO category 1-4 found in abdomen and pelvis are discussed. Part 2 will focus on common tumors from remainder of the WHO categories.

High-resolution phased array external magnetic resonance imaging (MRI) is the first investigation of choice in rectal cancer for local staging, both in the primary and restaging situations. Use of MRI helps differentiate between those with good prognosis, which can be offered upfront surgery and the poor prognostic cases where treatment intensification is needed. MRI identified poor prognostic factors are threatened or involved mesorectal fascia, T3 tumors with >5 mm extramural spread, those with extramural vascular invasion, pelvic sidewall nodes and mucinous tumors. At restaging, use of MRI helps evaluate response and an MR tumor regression grading system is being evaluated. Complete response seen on clinical examination and endoscopy, needs confirmation on MRI using both T2-weighted and diffusion-weighted sequences to justify a "watch and wait" approach. In this subset of patients, MRI also plays a role in monitoring and detecting early regrowth. In those with partial response, MRI helps define surgical margins and can be used as a roadmap to decide between sphincter preserving surgeries and radical sphincter sacrificing surgeries; pelvic exenteration and pelvic sidewall lymph node dissection. Poor responders on MRI may benefit from adjuvant chemotherapy. Use of MRI thus helps in individualizing treatment in rectal cancer.

Pelvic organ prolapse (POP) is assessed differently by gynecologists and radiologists. It is clinically staged by physical examination using the POP-Q (Pelvic Organ Prolapse Quantification) system and radiologically staged by modalities such as by Magnetic Resonance Defecography (MRD). The purpose of this study was to correlate the two methods of staging pelvic organ prolapse for each pelvic compartment by comparing correlative anatomic points and differences in technique. This understanding will help synthesize information from two different perspectives and bridge the gap between multiple specialists who participate in the care of patients with complex pelvic floor disorders. A retrospective single institution study comparison of patients who underwent both dynamic magnetic resonance pelvic floor imaging and pelvic organ prolapse quantification (POP-Q) at our medical center was done. Two urogynecologists performed the POP-Q and one fellowship-trained radiologist interpreted the MRD and both staged pelvic organ prolapse independently. A total of 280 patients underwent magnetic resonance imaging (MRI) of the pelvic floor from 1/2013 to 12/2017, of whom 68 met our inclusion criteria. When compared to POP-Q, MRI has strong, moderate, and weak correlation for quantification of anterior, middle, and posterior compartment prolapse, respectively. POP-Q measurements Aa, Ba, C, and D are analogous to true pelvic anatomical landmarks which are directly and consistently measurable by MRI, hence accounting for the better correlation in anterior and middle compartments when compared to measurements Ap and Bp which do not correlate with true anatomical landmarks, and hence can explain the weak correlation for posterior compartment prolapse. When comparing POP-Q to MRI, anterior and middle compartment prolapse have better correlation than posterior compartment prolapse. Inherent differences that exist in technique and anatomic landmarks used for staging pelvic organ prolapse by clinical exam and imaging criteria account for this. MRD, however, still provides anatomic details on static images, real time simultaneous overview of multi-compartmental prolapse, characterizes contents of cul-de-sac hernias and rectal evacuation on dynamic imaging. Corroborative information derived from both methods of staging organ will result in optimum patient care.

The presence of abnormal air collection on an imaging study is quite often the reason as well as the solution to a diagnostic dilemma. The purpose of this review article is to develop an understanding of anatomical localization and determine etiology of abnormal air collections in the abdomen and pelvis. Abnormal air collections are commonly encountered on imaging studies on a daily basis, and this article will help familiarize the interpreting radiologist with the pathophysiology of these collections and help solve various diagnostic challenges and avoid potential pitfalls.

Background and Aims: Parsonage Turner Syndrome is a well known clinical entity. Several excellent articles have succinctly described Magnetic Resonance Imaging (MRI) findings in PTS. However, these articles have inferred neural involvement in PTS based on the patterns of denervation of muscles in the shoulder region. The aim of this study is to directly visualize the distribution and extent of abnormality in MR Neurography (MRN) of the brachial plexus in known cases of brachial plexus neuritis or Parsonage-Turner Syndrome (PTS). Methods: 15 patients who were diagnosed with PTS based on clinical and electrophysiological findings participated in the study. MRN of the brachial plexus was done in a 1.5T system using a combination of T1W (T1-weighted), T2W (T2-weighted) fat-saturated, STIR (Short Tau Inversion Recovery), 3D STIR SPACE (Sampling Perfection with Application Optimized Contrasts) and 3D T2W SPACE sequences. Findings were recorded and assessed. Results: The age range of our patients was 7-65 years (mean 37.87 years). Most of the patients had unilateral symptoms. All patients had weakness in shoulder abduction. Other common associated complaints included pain in the shoulder/neck/arm and preceding fever. MRN revealed the percentage of involvement of roots, trunks, cords and terminal branches was 53.3%, 46.7%, 40% and 13.3% respectively. Evidence of muscle denervation in the form of edema, fatty infiltration and atrophy was noted in 8 (53.3%) patients. Conclusion: Most of the patients in this study had unilateral involvement on MRN. The roots were the commonest site of involvement followed by the trunks, cords and terminal branches. C5 was the most commonly involved root.

High-resolution magnetic resonance imaging (MRI) plays a pivotal role in the pretreatment assessment of primary rectal cancer. The success of this technique depends on obtaining good-quality high-resolution T2-weighted images of the primary tumor, orthogonal to rectal lumen. The goal of magnetic resonance staging is to identify patients who will benefit from neoadjuvant therapy prior to surgery to minimize postoperative recurrence and planning of optimal surgical approach. MRI also facilitates optimal identification of important prognostic factors, which improves both treatment selection and posttreatment follow-up. The objective of this article is to review the existing literature and provide a concise update on various aspects of rectal cancer imaging, discuss the current role of advanced imaging techniques such as diffusion-weighted and perfusion imaging in the evaluation of rectal cancer, and to assess response to therapy.

Introduction Magnetic resonance neurography (MRN) is a newer imaging technique that is increasingly used for detailed visualization of peripheral nerves not reliably achieved with conventional imaging modalities. Although MRN has been previously characterized in the literature, few studies have assessed its utility to neurosurgery, where there is potentially substantial impact particularly with preoperative assessment. In this article, we performed a retrospective review of cases in which MRN was used for clinical evaluation and surgical decision making. Methods MRN, clinical assessment, and operative decision making were retrospectively assessed in 206 consecutive patients at our institution between 2015 and 2018. Results MRN was determined to lead to a change in diagnosis or surgical decision making in 44 patients (21.4%: 27 female, 17 male). These were classified into 6 major diagnostic categories: trauma, postsurgical evaluation, compressive/degenerative conditions, tumors, neuritis/inflammation, and other neurogenic lesions. Nine representative cases were selected from these categories to highlight the range of neurosurgical pathologies in which MRN was useful in diagnostic assessment and surgical decision making. Conclusions MRN is an underused resource with great potential value in the diagnoses, surgical planning, and postoperative assessment of various neurosurgical conditions. These present incremental utility to the neurosurgeon as well as socioeconomic benefit in the detection of potentially surgically treatable lesions.

Soft-tissue sarcomas are a diverse group of rare mesenchymal malignancies accounting for only 1% of all solid adult malignancies. These have been categorized in 12 broad groups by the World Health Organization (WHO) with their recent update in 2013. Majority of them lack specific imaging features serving as imaging conundrums for a radiologist. These are often large masses at presentation as they are asymptomatic or cause vague clinical symptoms. These tumors are challenging for surgeons as well as they find it difficult to achieve complete resection because of complex intra-abdominal anatomy and their close relationship with critical structures. Often, a multidisciplinary approach is required to decide on the most appropriate management for these complex cases so as to provide optimal patient care. Knowledge of the WHO classification, pathologic features, and treatment options available helps the radiologist make a meaningful contribution in multidisciplinary discussions of such cases and overall patient care. Liposarcoma (well-differentiated and dedifferentiated liposarcomas), leiomyosarcoma, and gastrointestinal stromal tumor are the 3 most common primary intra-abdominal sarcomas. In part 1 of this article, general features of soft-tissue sarcomas and some of the common tumors from WHO category 1-4 found in abdomen and pelvis are discussed. Part 2 will focus on common tumors from remainder of the WHO categories.

To study the use of cardiac magnetic resonance (CMR) feature tracking technique in evaluation of myocardial amyloidosis.CMR scans of 28 patients with biopsy proven myocardial amyloidosis and 35 controls were reviewed. Conventional short axis, vertical long axis, and 4-chamber cine steady-state free precession images from CMR scans were used to generate radial, circumferential, and longitudinal myocardial strain maps using feature tracking software. Global and regional peak radial, circumferential, and longitudinal strain values were computed.There were significant decreases in radial, circumferential, and longitudinal strains in patients with myocardial amyloidosis globally and across layers (all P0.001). Strain was relatively preserved for the apex and most affected for the basal level. The area under the receiver operating characteristic curve for base peak radial, circumferential, and longitudinal strain 0.899, 0.884, and 0.866 and cut offs of 22.9, -13.3, and -10.9, respectively, were determined by receiver operating characteristic analysis. CMR feature tracking strain analysis of base-level strain parameters was able to differentiate patients with myocardial amyloidosis from those without myocardial amyloid with high sensitivity (82.5%) and specificity (82.9%) particularly for radial strain. The maximum sensitivity (89.3%) was achieved if any of the 3 parameters were abnormal, and the maximum specificity (88.6%) when all 3 parameters were abnormal.Myocardial amyloidosis produces significant changes in regional and global strain parameters, and the peak radial and circumferential strain are the most affected at the basal layer.

Crohn's disease (CD) is a chronic inflammatory bowel disease that often requires frequent imaging of patients in order to detect active disease and other complications related to disease activity. While endoscopy is the gold standard for diagnosis, it may be contraindicated in some patients and has a limited role in detecting deep submucosal/mesenteric diseases and intra abdominal complications. In recent years, magnetic resonance enterography (MRE) has evolved as a noninvasive, radiation free imaging modality in the evaluation of patients with CD. This review article will focus on role of MRE in imaging patients with CD with emphasis on technical considerations, systematic image interpretation, differential diagnoses, and the role of imaging in deciding treatment options for patients.

Musculoskeletal pathologies in the pelvis encompass a wide variety of lesions including femoroacetabular impingement, athletic pubalgia, ischiofemoral impingement, and apophyseal avulsion injuries. Magnetic resonance imaging is the noninvasive imaging modality of choice for the diagnosis and management of these lesions. In this article, the authors discuss the nonneoplastic musculoskeletal lesions in the pelvis, with illustrations and relevant case examples.

Diffuse infiltrative neurofibroma is a rare clinical entity that can pose a diagnostic challenge not only due to its rarity but also due to its varied clinical, radiological, and histological features. Our case illustrates how this entity may be misdiagnosed on clinical and pathological examination. Radiological imaging plays a critical and collaborative role in guiding clinicians and pathologists when faced with this challenging diagnosis.

In an era of declining reimbursements and tightening of the job market, today's radiologists are forced to "make do with less." With the rollout of the Patient Protection and Affordable Care Act, commonly called "Obamacare," radiologists will be expected not only to interpret studies but to also take on many additional roles, adding a new layer of complexity to already demanding daily duties. These changes make it more important than ever to develop a personal workflow management system incorporating some of the most potent productivity tools. In this article, the authors discuss current productivity techniques and related software with the most potential to help radiologists keep up with the ever increasing demands on their time at the work place and help us lead more balanced lives.

Magnetic resonance imaging has become more frequently utilized for staging, preoperative planning, and post-neoadjuvant evaluation of rectal cancer. It offers detailed resolution of the layers of the rectal wall, visualization of the mesorectal fascia, and identification of locoregional nodal involvement. Many advances have been made since the original protocols and include the use of phased-array coils, orthogonally obtained images and 3-dimensional sequences, the use of diffusion-weighted and perfusion protocols to better evaluate the tumor before and after neoadjuvant therapy, and the development of techniques to better evaluate metastatic nodes. Magnetic resonance imaging shows similar accuracy to endorectal ultrasound when staging and offers a less invasive technique that is not limited by patient discomfort or decreased luminal size. This article is meant to provide an update on the recent advances in rectal cancer imaging while addressing the controversial issues that exist in staging, technique, and imaging protocol.

Radiologic procedures form one of the cornerstones of diagnosis in hematological malignancies. Various radiological procedures are essential for the diagnosis, assessment of the therapeutic response, to identify disease relapse, and to evaluate for complications pre- and post-transplantation. The significance of radiology and radiological procedures in stem cell transplantation is expected to grow. In this chapter, we discuss the radiologic procedures and review the key imaging modalities and implications related to pediatric hematopoietic stem cell transplant (HSCT). We will also discuss the role of radionuclide Imaging for patients undergoing hematopoietic stem cell transplantation with a brief review of use of radio-labeled MIBG imaging in children with Neuroblastoma.

Multiple myeloma (MM) is an incurable plasma cell malignancy in which abnormal plasma cells accumulate in the bone marrow manifesting as osteolytic lesions in approximately 80% of the patients. Since bone disease is a hallmark of MM, sensitive imaging techniques directed at the detection of early bone lesions may be predictive of MM progression. Even though the current guideline for assessment of MM involves traditional skeletal survey, its limitations are well documented. However, several techniques have evolved in the preclinical cancer drug discovery including molecular and non-invasive imaging techniques, such as, low dose CT, molecularly targeted PET, MRI, single positron emission computed tomography, ultrasound and approaches like bioluminescence and fluorescence imaging. These techniques hold great promise in early diagnosis and monitoring of the disease and each has its share of advantages and disadvantages. An ideal technique should not alter the subject, should allow repeated measurements during the time course of the disease, should be sensitive enough to detect early disease and should have reasonably high specificity. However such technique is difficult to devise and test directly in human subjects due to technical challenges and ethical considerations and most of the pre-clinical research is done on the small animals.

We describe the efficacy of time-resolved MR angiography in diagnosing a case of pelvic congestion syndrome (PCS). MR angiography, using four-dimensional (4D) TRAK (Time-Resolved Angiography using Keyhole) technique was used in an 81-year-old woman presenting with low backache, pelvic pain, and left pelvic fullness. Dynamic images were obtained in multiple vascular phases including arterial, arteriovenous, and venous phases. The high temporal resolution of 4D TRAK could demonstrate early retrograde left ovarian vein filling as well as multiple dilated pelvic varices, allowing the prospective diagnosis of PCS to be made. Although uncommon in this age group, the diagnosis was subsequently confirmed on conventional catheter venography with symptomatic relief after successful embolization of the incompetent left ovarian vein. The MRA and correlative catheter venography images are presented in this case report. J. Magn. Reson. Imaging 2010;32:700–704. © 2010 Wiley-Liss, Inc.

Full article available online at Healio.com/Orthopedics Figure: Coronal computed tomography scan (A) showing a large hypervascular intramuscular mass. Coronal (B) and axial (C) magnetic resonance T2 fatsaturated images showing diffuse increased signal of the adductor magnus muscle, with fluid in the perimuscular fascial planes. Coronal T1-weighted image showing subtle diffuse hypointensity of the muscle (D). Diabetic myonecrosis is a rare complication of long-standing diabetes mellitus that presents as acute onset of swelling and pain of the affected muscles. The differential diagnosis includes cellulitis/pyomyositis, necrotizing fasciitis, neoplasm, and deep venous thrombosis (DVT). Missed diagnoses can lead to unnecessary invasive diagnostic procedures and inappropriate treatment. The diagnosis is established by the clinical presentation and findings on magnetic resonance imaging (MRI) scan. A 30-year-old African-American man presented with a painful mass affecting the medial aspect of the right thigh for several months. Initial laboratory studies showed white blood cell count of 8800 cells/mm 3 , D-dimer value of 0.55 µg/mL, HgBA1c level of 15.1%, glucose level of 352 mg/dL, erythrocyte sedimentation rate of 22 mm/h, and C-reactive protein level of 222 mg/L. An MRI scan was obtained, and diabetic myonecrosis was diagnosed and treated. One year later, the patient had similar symptoms of pain in the contralateral thigh. Repeat workup and MRI scan were obtained. The MRI abnormalities originally seen in the right thigh 1 year earlier were present in the left thigh, with complete resolution of the abnormalities seen in the right thigh. Treatment with bed rest and analgesics resulted in symptom resolution. Patients with diabetic myonecrosis typically have no fever, normal white blood cell count, mildly increased erythrocyte sedimentation rate, and elevated C-reactive protein level in 50% of cases. They lack the radiologic signs of fascial enhancement or well-defined, rim-enhancing collections that are seen in necrotizing fasciitis and pyomyositis/abscess. The onset of severe pain and the lack of mass effect on imaging differentiate diabetic myonecrosis from tumor-like conditions such as vascular malformations or soft tissue tumors. Normal D-dimer levels and ultrasound Doppler examination of the extremity help to rule out DVT. The typical MRI scan findings and clinical presentation can lead to the diagnosis of diabetic myonecrosis, allowing the physician to avoid invasive tests, such as muscle biopsy, and to reassure patients that this condition is self-limiting with appropriate treatment.

Objectives:We present our institutional experience with dynamic time-resolved magnetic resonance angiography (DTR MRA) with delayed venous imaging for free fibula flap (FFF) patient selection. We sought to (1) determine the sensitivity of the test for vascular anomalies predisposing to limb-threatening complications and (2) assess the impact of the venous phase findings in patient selection.Methods:Retrospective review of 46 patients considered for mandibular reconstruction with FFF in an academic tertiary setting from 2009-2012. A DTR MRA was performed preoperatively in all cases. Both imaging and physical examination findings were used to determine patient eligibility for the procedure.Results:Thirteen patients (28.2%) had findings on DTR MRA excluding flap harvesting from the preferred leg, with atherosclerosis (n = 8) and anatomic variations (n = 4) being the most common findings. Eight of these patients (61.5%) underwent harvesting from the opposite leg, while 5 underwent reconstruction with a differ...

Objectives:Dynamic time-resolved magnetic resonance angiography (DTR MRA) is a novel imaging algorithm that allows for better visualization of small-caliber vessels when compared with standard MRA. We sought to estimate the technique sensitivity when compared with intraoperative findings.Methods:Retrospective review of 25 patients undergoing reconstruction with free fibula flap at an academic tertiary setting from 2009 to 2013. Preoperative DTR MRA was performed in all cases. Two radiologists performed blind reviews of the images and their findings were compared with surgical descriptions of the perforator anatomy.Results:Surgical exploration identified 32 perforators while DTR MRA identified 45 vessels. The technique confirmed the presence of perforators in 22 out of 23 patients with at least one perforator, and their absence in 1 out of 2 patients who had a negative exploration. There was a significant correlation in the number of perforators identified clinically and radiologically in each case (P = .0...

An accessory lobe of the liver is a rare congenital anomaly that can undergo torsion and present as an acute surgical emergency. It is rarely diagnosed preoperatively. We report the preoperative utility of CT scan and MRI in the diagnosis and surgical planning of a case of intermittent accessory hepatic lobe torsion.

Lung cancer screening programs for high-risk populations using low-dose computed tomography (LDCT) have been shown by a class I clinical trial to reduce lung cancer mortality by 20%. We present an overview of randomized and nonrandomized lung cancer screening trials and review some of the arguments advocating for or against the widespread implementation of such a screening program. Concerns regarding the use of LDCT screening for lung cancer include increased risk from radiation exposure, overdiagnosis of indolent tumors, and high numbers of false-positive results, which may increase patient anxiety and result in unnecessary procedures with potential complications. Current recommendations regarding diagnostic criteria and workup of positive screens as well as the risks and benefits of using LDCT for lung cancer screening are provided.

Increasing use of smartphones and handheld computers is accompanied by a rapid growth in the other related industries. Electronic books have revolutionized the centuries-old conventional books and magazines markets and have simplified publishing by reducing the cost and processing time required to create and distribute any given book. We are now able to read, review, store, and share various types of documents via several electronic tools, many of which are available free of charge. Additionally, this electronic revolution has resulted in an explosion of readily available Internet-based educational resources for the residents and has paved the path for educators to reach out to a larger and more diverse student population.

We are in the midst of an evolving educational revolution. Use of digital devices such as smart phones and tablet computers is rapidly increasing among radiologists who now regularly use them for medical, technical, and administrative tasks. These electronic tools provide a wide array of new tools to the radiologists allowing for faster, more simplified, and widespread distribution of educational material. The utility, future potential, and limitations of some these powerful tools are discussed in this article.

Cardiac magnetic resonance imaging (CMRI) plays an important role in the diagnosis and follow-up of apical ballooning syndrome (takotsubo syndrome), a recently described cardiac condition characterised by transient dyskinesia of the left ventricle secondary to an acute emotional event. We present the CMRI findings in a 53-year-old female diagnosed with apical ballooning syndrome and discuss its value in the diagnosis and follow-up of this condition.