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Objectives: To introduce and evaluate a simple method for assessing joint inflammation and structural damage on whole-body MRI (WBMRI) in juvenile idiopathic arthritis (JIA), which is usable in clinical practice., Methods: The proposed system utilizes post-contrast Dixon WBMRI scans. Joints are assessed for synovitis (grade 0-2) and structural damage (present/absent) at 81 sites. The synovitis grading is based on features including above-normal intensity synovial enhancement, synovial hypertrophy, joint effusion, subarticular bone marrow oedema and peri-articular soft tissue oedema.This system was evaluated in a prospective study of 60 young people (47 patients with JIA and 13 controls with non-inflammatory musculoskeletal pain) who underwent a WBMRI. Three readers (blinded to diagnosis) independently reviewed all images and re-reviewed 20 individual scans. The intra- and inter-reader overall agreement (OA) and the intra- and inter-reader Gwet's agreement coefficients 2 (GAC2) were measured for the detection of a) participants with ≥1 joint with inflammation or structural damage and b) joint inflammation or structural damage for each joint., Results: The inter-reader OA for detecting patients with ≥1 joint with inflammation, defined as grade 2 synovitis (G2), and ≥1 joint with structural damage were 80% and 73%, respectively. The intra-reader OA for readers 1-3 was 80-90% and 75-90%, respectively. The inter-reader OA and GAC2 for joint inflammation (G2) at each joint were both ≥85% for all joints but were lower if grade 1 synovitis was included as positive., Conclusion: The intra- and inter-reader agreements of this WBMRI assessment system are adequate for assessing objective joint inflammation and damage in JIA., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Objectives: To assess the frequency of joint inflammation detected by whole-body MRI (WBMRI) in young people (YP) with JIA and controls, and to determine the relationship between WBMRI-detected inflammation and clinical findings., Methods: YP aged 14-24 years, with JIA (patients) or arthralgia without JIA (controls), recruited from one centre, underwent a WBMRI scan after formal clinical assessment. Consensus between at least two of the three independent radiologists was required to define inflammation and damage on WBMRI, according to predefined criteria. YP with JIA were deemed clinically active as per accepted definitions. The proportions of YP with positive WBMRI scans for joint inflammation (one or more inflamed joint) as well as serum biomarkers were compared between active vs inactive JIA patients and controls., Results: Forty-seven YP with JIA (25 active and 22 inactive patients) and 13 controls were included. WBMRI detected joint inflammation in 60% (28/47) of patients with JIA vs 15% (2/13) of controls (difference: 44%, 95% CI 20%, 68%). More active than inactive JIA patients had WBMRI-detected inflammation [76% (19/25) vs 41% (9/22), difference: 35% (95% CI 9%, 62%)], and this was associated with a specific biomarker signature. WBMRI identified inflammation in one or more clinically inactive joint in 23/47 (49%) patients (14/25 active vs 9/22 inactive JIA patients)., Conclusions: WBMRI's validity in joint assessment was demonstrated by the higher frequency of inflammation in JIA patients vs controls, and in active vs inactive JIA patients. WBMRI found unsuspected joint inflammation in 49% YP with JIA, which needs further investigation of potential clinical implications., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Aim: To evaluate the impact of recommendations from the 2019 consensus exercise conducted by radiologists and rheumatologists on the use of magnetic resonance imaging (MRI) to investigate axial spondyloarthritis (axSpA) in clinical practice., Materials and Methods: A freedom of information (FOI) request was used to assess the use of MRI in the diagnosis of axSpA and radiologists' awareness of the 2019 guidance across all NHS Trusts and Health Boards in the UK, including England, Scotland, Northern Ireland, and Wales., Results: The FOI request was sent to 150 Trusts/Health Boards, and 93 full responses were received. Of the 93 respondents (97%), 90 reported familiarity with the term axSpA and 70/93 (75%) reported familiarity with the 2019 recommendations. Awareness of recommendations regarding specific MRI features supportive of the diagnosis of axSpA was 74/93 (80%) for the sacroiliac joints (SIJs) and 66/93 (71%) for the spine. The median wait for MRI acquisition was 2-3 months. Fifty-two of the 93 (56%) reported at least some outsourcing of axSpA MRI (33%/29% for specialist/non-specialist outsourcing respectively); 32/93 (34%) reported some scans being reported in-house by non-musculoskeletal radiologists., Conclusion: There have been several positive developments in the understanding and use of MRI for the diagnosis of axSpA in the UK since the 2017 survey, although substantial scope for further improvement remains. Several new challenges have also emerged, including the increase in waiting times, reliance on outsourcing, and the reporting of MRI by non-musculoskeletal radiologists., (Copyright © 2023. Published by Elsevier Ltd.)

Objective: Objective assessments of disease activity and response to treatment in axial spondyloarthritis (axSpA) remain a challenge; quantitative imaging biomarkers (QIBs) of inflammation could enhance assessments of disease activity and therapeutic response. We aimed to determine the responsiveness of QIBs obtained from diffusion-weighted imaging (DW-MRI) and chemical shift-encoded MRI (CSE-MRI) using the partially automated Bone Edema and Adiposity Characterisation with Histograms (BEACH) software tool in axSpA patients undergoing biologic therapy., Methods: We conducted a prospective longitudinal cohort study, including 30 patients with axSpA undergoing biologic therapy. Patients were scanned before and after biologic therapy using conventional MRI, DWI and CSE-MRI at 3T. Apparent diffusion coefficient (ADC) and proton density fat fraction (PDFF) were assessed using the BEACH tool (https://github.com/TJPBray/BEACH), and conventional MR images were assessed using established visual scoring methods by expert radiologists. Responsiveness - the ability of the MRI measurements to capture changes in disease occurring as a result of biologic therapy - was assessed using the standardized response mean (SRM). Inter-reader reliability of the ADC and PDFF maps was assessed using Bland-Altman limits of agreement analysis and the intraclass correlation coefficient., Results: Responsiveness to therapy was moderate for ADC-based parameters (SRM 0.50) and comparable to established visual scoring methods for bone marrow oedema (SRM 0.53). Interobserver variability was lower for QIBs compared with conventional visual scores methods., Conclusions: QIBs measured using the BEACH tool are sensitive to changes in inflammation in axSpA following biologic therapy, with similar responsiveness and lower interobserver variability to visual scoring by expert radiologists., Advances in Knowledge: QIBs measured using the partially automated BEACH tool offer an objective measure of response to biologic therapy in axSpA.

Purpose: Remission of type 2 diabetes (T2D) can be achieved by many, but not all, people following bariatric/metabolic surgery. The mechanisms underlying T2D remission remain incompletely understood. This observational study aimed to identify novel weight-loss independent clinical, metabolic and genetic factors that associate with T2D remission using comprehensive phenotyping., Materials and Methods: Ten patients without T2D remission (non-remitters) were matched to 10 patients with T2D remission (remitters) for age, sex, type of surgery, body weight, BMI, post-operative weight loss, duration from surgery and duration of T2D. Detailed body composition assessed using magnetic resonance imaging, gut hormones, serum metabolomics, insulin sensitivity, and genetic risk scores for T2D and anthropometric traits were assessed., Results: Remitters had significantly greater β-cell function and circulating acyl ghrelin levels, but lower visceral adipose tissue (VAT): subcutaneous adipose tissue (SAT) ratio than non-remitters. Branched-chain amino acids (BCAAs) and VLDL particle size were the most discriminant metabolites between groups. A significant positive correlation between, VAT area, VAT:SAT ratio and circulating levels of BCAAs was observed, whereas a significant negative correlation between BCAAs and β-cell function was revealed., Conclusion: We highlight a potentially novel relationship between VAT and BCAAs, which may play a role in glucoregulatory control. Improvement in β-cell function, and the role ghrelin plays in its recovery, is likely another key factor influencing T2D remission post-surgery. These findings suggest that adjunctive approaches that target VAT loss and restoration of BCAA metabolism might achieve higher rates of long-term T2D remission post-surgery., (© 2023. The Author(s).)

Purpose: Short-inversion-time inversion-recovery MRI is used widely for imaging bone and soft-tissue inflammation in rheumatic inflammatory diseases, but there is no widely available quantitative equivalent of this sequence. This limits our ability to objectively assess inflammation and distinguish it from other processes. To address this, we investigate the use of the widely available Dixon turbo spin echo (TSE Dixon) sequence as a practical approach to simultaneous water-specific T 2 (T 2water ) and fat fraction (FF) measurement., Methods: We use a series of TSE Dixon acquisitions with varying effective TEs (TE eff ) to quantify T 2water and FF. The validity of this approach is assessed in a series of phantom and in vivo experiments, with reference values provided by Carr-Purcell-Meiboom-Gill acquisitions, MRS, and phantoms. The effect of inflammation on parameter values is evaluated in patients with spondyloarthritis., Results: The T 2water estimates obtained from TSE Dixon were accurate compared with the reference values from Carr-Purcell-Meiboom-Gill and spectroscopy in both fat-free environments and in the presence of fat. FF measurements with T 2water correction from TSE Dixon were accurate from 0% to 60% FF and were not confounded by T 2water variations. In vivo imaging produced good quality images that were artifact free, produced plausible T 2 values, separating and quantifying the effect of inflammation on T 2water and FF., Conclusion: The T 2water and FF measurements based on TSE Dixon with effective TE increments are accurate over a range of T 2 and FF values and could provide a widely available quantitative alternative to the short-inversion-time inversion-recovery sequence for imaging inflamed tissue., (© 2023 The Authors. Magnetic Resonance in Medicine published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Qualitative visual assessment of MRI scans is a key mechanism by which inflammation is assessed in clinical practice. For example, in axial spondyloarthritis (axSpA), visual assessment focuses on the identification of regions with increased signal in the bone marrow, known as bone marrow oedema (BMO), on water-sensitive images. The identification of BMO has an important role in the diagnosis, quantification and monitoring of disease in axSpA. However, BMO evaluation depends heavily on the experience and expertise of the image reader, creating substantial imprecision. Deep learning-based segmentation is a natural approach to addressing this imprecision, but purely automated solutions require large training sets that are not currently available, and deep learning solutions with limited data may not be sufficiently trustworthy for use in clinical practice. To address this, we propose a workflow for inflammation segmentation incorporating both deep learning and human input. With this 'human-machine cooperation' workflow, a preliminary segmentation is generated automatically by deep learning; a human reader then 'cleans' the segmentation by removing extraneous segmented voxels. The final cleaned segmentation defines the volume of hyperintense inflammation (VHI), which is proposed as a quantitative imaging biomarker (QIB) of inflammation load in axSpA. We implemented and evaluated the proposed human-machine workflow in a cohort of 29 patients with axSpA who had undergone prospective MRI scans before and after starting biologic therapy. The performance of the workflow was compared against purely visual assessment in terms of inter-observer/inter-method segmentation overlap, inter-observer agreement and assessment of response to biologic therapy. The human-machine workflow showed superior inter-observer segmentation overlap than purely manual segmentation (Dice score 0.84 versus 0.56). VHI measurements produced by the workflow showed similar or better inter-observer agreement than visual scoring, with similar response assessments. We conclude that the proposed human-machine workflow offers a mechanism to improve the consistency of inflammation assessment, and that VHI could be a valuable QIB of inflammation load in axSpA, as well as offering an exemplar of human-machine cooperation more broadly., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Hepburn et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Imaging, and particularly MRI, plays a crucial role in the assessment of inflammation in rheumatic disease, and forms a core component of the diagnostic pathway in axial spondyloarthritis. However, conventional imaging techniques are limited by image contrast being non-specific to inflammation and a reliance on subjective, qualitative reader interpretation. Quantitative MRI methods offer scope to address these limitations and improve our ability to accurately and precisely detect and characterise inflammation, potentially facilitating a more personalised approach to management. Here, we review quantitative MRI methods and emerging quantitative imaging biomarkers for imaging inflammation in axial spondyloarthritis. We discuss the potential benefits as well as the practical considerations that must be addressed in the movement toward clinical translation of quantitative imaging biomarkers.

Competing Interests: CC reports grant funding from Action Medical Research. TB is funded by a National Institute for Health and Care Research (NIHR) Clinical Lectureship and reports grant funding from NIHR Biomedical Research Centre, and honorarium for manuscript writing from the National Ankylosing Spondylitis Society. VC reports grant funding from the British Society of Rheumatology. MAH-C declares no competing interests.

Objective: To evaluate the relation between whole-body MRI (WBMRI) outcomes and disease activity measures, including clinical examination, composite scores, and other imaging outcomes, and the ability of WBMRI to detect treatment response in patients with inflammatory arthritis (IA) across age., Methods: Human studies published as full text or abstract in the PubMed and MEDLINE and Cochrane databases from inception to 11th April 2021 were systematically and independently searched by two reviewers. Studies including patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondyloarthritis (SpA), juvenile idiopathic arthritis (JIA) or unclassified inflammatory arthritis (UA) who underwent WBMRI and which reported on disease outcomes were included., Results: Nineteen full-text studies were eligible for inclusion: 2 interventional, 7 retrospective and 10 prospective observational studies, comprising 540 participants (SpA 38.7%, RA 24.8%, JIA 17.8%, PsA 11.5%, healthy controls 5.9%, UA 1.3%). Abstracts of 6 conference papers were reported separately. Five studies in PsA and SpA and 4 in RA measured the frequency of WBMRI-detected and clinically-detected synovitis, and all found the former to be more frequent. Less enthesitis was detected by WBMRI than clinical examination in 5/8 studies. After biologic treatment, the WBMRI inflammation scores declined in 3 studies in SpA and 2 in RA, whilst in 3 studies the results were equivocal., Conclusion: The ability of WBMRI to assess disease activity and treatment response in IA was adequate overall. Further studies are needed to corroborate WBMRI findings with IA outcomes and investigate the clinical value of subclinical inflammation., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To assess body composition in patients with non-small cell lung cancer (NSCLC) and colorectal cancer using whole-body MRI and relate this to clinical outcomes., Methods: 53 patients with NSCLC (28 males, 25 females; mean age 66.9) and 74 patients with colorectal cancer (42 males, 32 females; mean age 62.9) underwent staging whole-body MRI scans, which were post-processed to derive fat mass (FM), fat free mass (FFM) and skeletal muscle (SM) indices and SM fat fraction (FF). These were compared between the two cancer cohorts using two-sided t -tests and the chi-squared test. Measurements of body composition were correlated with outcomes including length of hospital stay, metastatic status and mortality., Results: Patients with NSCLC had significantly lower FFM ( p = 0.0071) and SM ( p = 0.0084) indices. Mean SM FF was greater in patients with NSCLC ( p = 0.0124) and was associated with longer hospital stay ( p = 0.035 ). There was no significant relationship between FM, FFM and SM indices and length of hospital stay, metastatic status or mortality., Conclusions: Patients with NSCLC had lower FFM and SM indices than patients with colorectal cancer and greater SMFF, indicating lower SM mass with fatty infiltration. These findings reflect differences in the phenotype of the two groups and suggest patients with lung cancer are more likely to require additional nutritional support., Advances in Knowledge: Body composition differs between NSCLC and colorectal cancer. Patients with NSCLC have both a reduced SM mass and greater SM FF suggesting that they are more nutritionally deplete than patients with colorectal cancer., (© 2021 The Authors. Published by the British Institute of Radiology.)

This paper proposes a task-driven computational framework for assessing diffusion MRI experimental designs which, rather than relying on parameter-estimation metrics, directly measures quantitative task performance. Traditional computational experimental design (CED) methods may be ill-suited to experimental tasks, such as clinical classification, where outcome does not depend on parameter-estimation accuracy or precision alone. Current assessment metrics evaluate experiments' ability to faithfully recover microstructural parameters rather than their task performance. The method we propose addresses this shortcoming. For a given MRI experimental design (protocol, parameter-estimation method, model, etc.), experiments are simulated start-to-finish and task performance is computed from receiver operating characteristic (ROC) curves and associated summary metrics (e.g. area under the curve (AUC)). Two experiments were performed: first, a validation of the pipeline's task performance predictions against clinical results, comparing in-silico predictions to real-world ROC/AUC; and second, a demonstration of the pipeline's advantages over traditional CED approaches, using two simulated clinical classification tasks. Comparison with clinical datasets validates our method's predictions of (a) the qualitative form of ROC curves, (b) the relative task performance of different experimental designs, and (c) the absolute performance (AUC) of each experimental design. Furthermore, we show that our method outperforms traditional task-agnostic assessment methods, enabling improved, more useful experimental design. Our pipeline produces accurate, quantitative predictions of real-world task performance. Compared to current approaches, such task-driven assessment is more likely to identify experimental designs that perform well in practice. Our method is not limited to diffusion MRI; the pipeline generalises to any task-based quantitative MRI application, and provides the foundation for developing future task-driven end-to end CED frameworks., Competing Interests: The authors have declared that no competing interests exist.

While perinatal risk factors are widely used to help identify those at risk for developmental dysplasia of the hip (DDH) within the first 6 to 8 weeks of life, limited data exist about their association with radiographic evidence of dysplasia in childhood. The purpose of this study was to determine which perinatal risk factors are associated with acetabular dysplasia in children who are ≥2 years of age., Methods: Pelvic radiographs were made in 1,053 children (mean age, 4.4 years [range, 2 to 7 years]) who had been assessed prospectively as having at least 1 of 9 widely accepted perinatal risk factors for DDH. Two radiologists who were blinded to patient risk factors, history, and age determined the acetabular index (AI). The primary outcome was defined as an AI >2 standard deviations from the Tönnis reference values ("severe" dysplasia). The secondary outcome was an AI of >20° at >2 years of age. The association between risk factors and outcomes was assessed using logistic regression. The effect of treatment in infancy was adjusted for in 37 hips., Results: Twenty-seven participants (3%) showed "severe" hip dysplasia; 3 of these had received treatment for DDH in infancy. Girls were more likely to experience this outcome (odds ratio [OR] = 2.59; 95% confidence interval [CI] = 1.04 to 6.46; p = 0.04); no other examined risk factors were significant. The secondary outcome appeared in 146 participants (14%), 12 of whom had received treatment in infancy. We observed the following predictors for this outcome: female sex (OR = 1.77; 95% CI = 1.21 to 2.59; p = 0.003), breech presentation (OR = 1.74; 95% CI = 1.08 to 2.79; p = 0.02), and being a firstborn child, which had a protective effect (OR = 0.67; 95% CI = 0.46 to 0.96; p = 0.03)., Conclusions: We identified a substantial number of cases that will require at least radiographic surveillance for mild and severe hip dysplasia; 92% had no prior diagnosis of DDH. Those who had been born breech were affected by this outcome even if ultrasonography of the hip had been normal at 6 to 8 weeks, suggesting a benefit from additional radiographic testing., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefits funding stream (PB-PG-0213-30046). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A253)., (Copyright © 2021 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Diffusion-weighted imaging has received attention as a method for characterizing inflammatory exudates in bone marrow in immune-mediated inflammatory diseases and reveals an increase in diffusivity in regions of bone marrow oedema. Various models of diffusion attenuation have been investigated but the model providing the best description of tissue pathophysiology in regions of marrow oedema is unknown. Determining the most appropriate model is an important step towards protocol optimization and the development of a robust and clinically useful method. We aimed to determine which of three candidate models of diffusion attenuation most accurately describes the acquired signal from normal and inflamed bone marrow. 11 subjects with spondyloarthritis and evidence of active inflammation (ie bone marrow oedema) on MRI and 17 patients with no evidence of active inflammation underwent diffusion-weighted imaging of the sacroiliac joints (b-values 0, 50, 100, 300 and 600 s/mm 2 ). Monoexponential, intravoxel incoherent motion (IVIM) and kurtosis models were fitted to the acquired signal from regions of interest in areas of bone marrow oedema and normal marrow. The three models were compared in terms of sum of squared error and information content (corrected Akaike information criterion). Model parameters were compared between regions of bone marrow oedema and regions of normal marrow. f the three models investigated, the IVIM model provided the best description of the signal over the 0-600 s/mm 2 range across normal and inflamed bone marrow. There was a particular advantage of the IVIM model in normal marrow, where it was best able to capture the pronounced fast diffusion component observed in several cases. However, IVIM and kurtosis effects both became smaller and the signal behaviour became closer to monoexponential in the presence of bone marrow oedema. Our data suggest that increases in D tissue (in the IVIM framework) might account for the reduced deviation from monoexponential behaviour in oedematous bone., (© 2020 The Authors. NMR in Biomedicine published by John Wiley & Sons Ltd.)

Objective: To demonstrate proof-of-concept for a quantitative MRI method using histographic analysis to assess bone marrow oedema and fat metaplasia in the sacroiliac joints., Materials and Methods: Fifty-three adolescents aged 12-23 with known or suspected sacroiliitis were prospectively recruited and underwent quantitative MRI (qMRI) scans, consisting of chemical shift-encoded (at 3 T) and diffusion-weighted imaging (at 1.5 T), plus conventional MRI (at 1.5 T) and clinical assessment. qMRI scans produced proton-density fat fraction (PDFF) and apparent diffusion coefficient (ADC) maps of the sacroiliac joints (SIJs), which were analysed using an in-house software tool enabling partially automated ROI definition and histographic analysis. Logistic regression and receiver operating characteristic (ROC) analyses assessed the predictive performance of ADC- and PDFF-based parameters in identifying active inflammation (oedema) and structural damage (fat metaplasia)., Results: ADC-based parameters were associated with increased odds of oedema (all p < 0.05); ROC-AUC was higher for histographic parameters representing the upper end of the ADC distribution than for simple averages. Similarly, PDFF-based parameters were associated with increased odds of fat metaplasia (all p < 0.05); ROC area-under-the-curve was higher for histographic parameters representing the upper end of the PDFF distribution than for simple averages. Both ADC- and PDFF-based histographic parameters demonstrated excellent inter- and intra-observer agreement (ICC > 0.9)., Conclusions: ADC-based parameters can differentiate patients with bone marrow oedema from those without, whilst PDFF-based parameters can differentiate patients with fat metaplasia from those without. Histographic analysis might improve performance compared with simple averages such as the mean and median and offers excellent agreement within and between observers., Key Points: • Quantitative MRI with histographic analysis can identify bone marrow oedema (an active inflammatory lesion) and fat metaplasia (a 'chronic' inflammatory lesion) in patients with spondyloarthritis. • The use of histographic analysis might improve the performance of quantitative MRI for detecting bone marrow oedema and fat metaplasia compared with simple averages such as the mean and median. • Bone marrow oedema and fat metaplasia are known to be of diagnostic and prognostic significance, and the proposed method could support clinical decisions around biologic (and other) therapies in spondyloarthritis.

Background: Quantification of fat by proton density fat fraction (PDFF) measurements may be valuable for the quantification and follow-up of pathology in multicenter clinical trials and routine practice. However, many centers do not have access to specialist methods (such as chemical shift imaging) for PDFF measurement. This is a barrier to more widespread trial implementation., Purpose/hypothesis: To determine the agreement between fat fraction (FF) measurements derived from 1) basic vendor-supplied sequences, 2) basic sequences with offline correction, and 3) specialist vendor-supplied methods., Study Type: Prospective., Population: Two substudies with ten and five healthy volunteers., Field Strength/sequence: Site A: mDixon Quant (Philips 3T Ingenia); Site B: IDEAL and FLEX (GE 1.5T Optima MR450W); Site C: DIXON, with additional 5-echo gradient echo acquisition for offline correction (Siemens 3T Skyra); Site D: DIXON, with additional VIBE acquisitions for offline correction (Siemens 1.5T Avanto). The specialist method at site A was used as a standard to compare to the basic methods at sites B, C, and D., Assessment: Regions of interest were placed on areas of subchondral bone on FF maps from the various methods in each volunteer., Statistical Tests: Relationships between FF measurements from the various sites and Dixon methods were assessed using Bland-Altman analysis and linear regression., Results: Basic methods consisting of IDEAL, LAVA FLEX, and DIXON produced FF values that were linearly related to reference FF values (P < 0.0001), but produced mean biases of up to 10%. Offline correction produced a significant reduction in bias in both substudies (P < 0.001)., Data Conclusion: FF measurements derived using basic vendor-supplied methods are strongly linearly related with those derived using specialist methods but produce a bias of up to 10%. A simple offline correction that is accessible even when the scanner has only basic sequence options can significantly reduce bias., Level of Evidence: 2 Technical Efficacy Stage: 1 J. Magn. Reson. Imaging 2020;52:298-306., (© 2020 International Society for Magnetic Resonance in Medicine.)

Objective: To identify the whole-body MRI (WB-MRI) image type(s) with the highest value for assessment of multiple myeloma, in order to optimise acquisition protocols and read times., Methods: Thirty patients with clinically-suspected MM underwent WB-MRI at 3 Tesla. Unenhanced Dixon images [fat-only (FO) and water-only (WO)], post contrast Dixon [fat-only plus contrast (FOC) and water-only plus contrast (WOC)] and diffusion weighted images (DWI) of the pelvis from all 30 patients were randomised and read by three experienced readers. For each image type, each reader identified and labelled all visible myeloma lesions. Each identified lesion was compared with a composite reference standard achieved by review of a complete imaging dataset by a further experienced consultant radiologist to determine truly positive lesions. Lesion count, true positives, sensitivity, and positive predictive value were determined. Time to read each scan set was recorded. Confidence for a diagnosis of myeloma was scored using a Likert scale. Conspicuity of focal lesions was assessed in terms of percent contrast and contrast to noise ratio (CNR)., Results: Lesion count, true positives, sensitivity and confidence scores were significantly higher when compared to other image types for DWI (P<0.0001 to 0.003), followed by WOC (significant for sensitivity (P<0.0001 to 0.004), true positives (P = 0.003 to 0.049) and positive predictive value (P< 0.0001 to 0.006)). There was no statistically significant difference in these metrics between FO and FOC. Percent contrast was highest for WOC (P = 0.001 to 0.005) and contrast to noise ratio (CNR) was highest for DWI (P = 0.03 to 0.05). Reading times were fastest for DWI across all observers (P< 0.0001 to 0.014)., Discussion: Observers detected more myeloma lesions on DWI images and WOC images when compared to other image types. We suggest that these image types should be read preferentially by radiologists to improve diagnostic accuracy and reporting efficiency., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To review quantitative magnetic resonance imaging (qMRI) methods for imaging inflammation in connective tissues and the skeleton in inflammatory arthritis. This review is designed for a broad audience including radiologists, imaging technologists, rheumatologists and other healthcare professionals., Methods: We discuss the use of qMRI for imaging skeletal inflammation from both technical and clinical perspectives. We consider how qMRI can be targeted to specific aspects of the pathological process in synovium, cartilage, bone, tendons and entheses. Evidence for the various techniques from studies of both adults and children with inflammatory arthritis is reviewed and critically appraised., Results: qMRI has the potential to objectively identify, characterize and quantify inflammation of the connective tissues and skeleton in both adult and pediatric patients. Measurements of tissue properties derived using qMRI methods can serve as imaging biomarkers, which are potentially more reproducible and informative than conventional MRI methods. Several qMRI methods are nearing transition into clinical practice and may inform diagnosis and treatment decisions, with the potential to improve patient outcomes., Conclusions: qMRI enables specific assessment of inflammation in synovium, cartilage, bone, tendons and entheses, and can facilitate a more consistent, personalized approach to diagnosis, characterisation and monitoring of disease., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To summarize the evidence on the performance of MRI for the diagnosis of axial SpA., Methods: This was a systematic literature review of all studies from January 2013 to March 2017 including adult patients with clinically suspected axial SpA undergoing MRI. Studies from a previously published systematic literature review up to January 2013 were also included., Results: Thirty-one studies were included. Six studies demonstrated good sensitivity and specificity for SI joint (SIJ) bone marrow oedema (BMO). Specificity was increased by the presence of other structural lesions alongside BMO, particularly erosions or fat infiltration. Four studies addressed the utility of SIJ fat infiltration, finding good sensitivity but poor specificity. SIJ erosions showed good specificity in five studies. Studies addressing high T1 signal in the SIJ, fluid signal in the SIJ, ankylosis, sclerosis, capsulitis, backfill and vacuum phenomenon reported limited diagnostic value. In the spine, four studies reported moderate sensitivity and specificity for corner inflammatory lesions, and four reported poor sensitivity and specificity for spinal fat infiltration. Five studies evaluated the added value of spinal MRI over SIJ MRI alone, with variable results depending on the cohort. Six studies addressed the effect of acquisition parameters on diagnostic accuracy: fat-saturated T2-weighted imaging and short tau inversion recovery (STIR) imaging showed comparable utility in identifying BMO. Three studies showed that gadolinium was of minimal added value in the detection of BMO., Conclusions: These results confirmed the diagnostic utility of MRI in axial SpA. Performance varied according to the characteristics of the cohort and the number and combination of MRI lesions considered., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: To develop evidence-based recommendations on the use of MRI in the diagnosis of axial SpA (axSpA)., Methods: A working group comprising nine rheumatologists and nine musculoskeletal radiologists with an interest in axSpA was established, with support from the British Society of Spondyloarthritis (BRITSpA). Two meetings were held. In the first meeting, research questions were formulated. In the second meeting, the results of a systematic literature review designed to inform the recommendations were reviewed. An anonymized Delphi process was used to formulate the final set of recommendations. For each recommendation, the level of evidence and strength of recommendation was determined. The level of agreement was assessed using a 0-10 numerical rating scale., Results: Two overarching principles were formulated, as follows: The diagnosis of axSpA is based on clinical, laboratory and imaging features (overarching principle 1), and patients with axSpA can have isolated inflammation of either the sacroiliac joints or the spine (overarching principle 2). Seven recommendations addressing the use of MRI in the assessment of patients with suspected axSpA were formulated, covering topics including recommended sequences, anatomical coverage, acquisition parameters and interpretation of active and structural MRI lesions. The level of agreement for each recommendation was very high (range 8.8-9.8)., Conclusion: A joint rheumatology and radiology consensus on the acquisition and interpretation of MRI in axSpA diagnosis was achieved, and a research agenda formulated. This consensus should help standardize practice around MRI and ensure a more informed, consistent approach to the diagnosis of axSpA., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: To evaluate the relationship between bone mineral density (BMD) and magnetic susceptibility, and between proton density fat fraction and susceptibility, in inflamed trabecular bone., Methods: Two different phantoms modeling the fat fraction (FF) and BMD values of healthy bone marrow and disease states were scanned using a multiecho gradient echo acquisition at 3T. After correction for fat-water chemical shift, susceptibility mapping was performed, and susceptibility measurements were compared with BMD and FF values using linear regression. Patients with spondyloarthritis were scanned using the same protocol, and susceptibility values were calculated in areas of inflamed bone (edema) and fat metaplasia, both before and after accounting for the contribution of fat to the total susceptibility., Results: Susceptibility values in the phantoms were accurately described by a 2D linear function, with a negative correlation between BMD and susceptibility and a positive correlation between FF and susceptibility (adjusted R 2 = 0.77; P = 3·10 -5 ). In patients, significant differences in susceptibility were observed between fat metaplasia and normal marrow, but these differences were eliminated by removing the fat contribution to the total susceptibility., Conclusions: BMD and proton density fat fraction both influence the total susceptibility of bone marrow and failure to account for the fat contribution could lead to errors in BMD quantification. We propose a method for removing the fat contribution from the total susceptibility, based on the observed linear relationship between susceptibility and FF. In inflamed bone, the overall increase in susceptibility in areas of fat metaplasia is at least partly due to increased fat content., (© 2019 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine.)

Objective: To assess the temporal relationship between initiating biologic therapy and magnetic resonance imaging (MRI) scores of inflammation and structural damage in young patients with spondyloarthritis., Methods: A local adolescent/young adult patient rheumatology database was searched for patients ages 12-24 years who had evidence of sacroiliitis on MRI and a clinical diagnosis of enthesitis-related arthritis (ERA) with axial involvement or nonradiographic axial spondyloarthritis. Patients treated with tumor necrosis factor inhibitor (TNFi) therapy who had undergone a minimum of 1 MRI scan before and 2 MRI scans after starting TNFi therapy (over ≥2 years) were included. Images of the sacroiliac joints were scored for inflammation and structural abnormalities (including erosions, fat metaplasia, and fusion). The effects of TNFi therapy and of time since initiation of TNFi therapy on inflammation and structural abnormalities were assessed using a mixed-effects regression analysis., Results: Twenty-nine patients (ages 12-23 years) with ERA or nonradiographic axial spondyloarthritis who underwent TNFi therapy were included. Inflammation scores were significantly lower in patients receiving TNFi treatment (P = 0.013), but there was no significant effect of time from TNFi initiation on inflammation (P = 0.125). Conversely, there was no significant effect of active TNFi treatment on fusion scores (P = 0.308), but fusion scores significantly increased with time from TNFi initiation (P < 0.001); a similar positive relationship between time since biologic start and fat metaplasia scores was observed., Conclusion: TNFi therapy failed to prevent the eventual development of joint ankylosis in this cohort of young patients with spondyloarthritis, despite a substantial reduction in inflammation with TNFi therapy., (© 2018 The Authors. Arthritis & Rheumatology published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.)

Adipose cells have traditionally been viewed as a simple, passive energy storage depot for triglycerides. However, in recent years it has become clear that adipose cells are highly physiologically active and have a multitude of endocrine, metabolic, haematological and immune functions. Changes in the number or size of adipose cells may be directly implicated in disease (e.g. in the metabolic syndrome), but may also be linked to other pathological processes such as inflammation, malignant infiltration or infarction. MRI is ideally suited to the quantification of fat, since most of the acquired signal comes from water and fat protons. Fat fraction (FF, the proportion of the acquired signal derived from fat protons) has, therefore, emerged as an objective, image-based biomarker of disease. Methods for FF quantification are becoming increasingly available in both research and clinical settings, but these methods vary depending on the scanner, manufacturer, imaging sequence and reconstruction software being used. Careful selection of the imaging method-and correct interpretation-can improve the accuracy of FF measurements, minimize potential confounding factors and maximize clinical utility. Here, we review methods for fat quantification and their strengths and weaknesses, before considering how they can be tailored to specific applications, particularly in the gastrointestinal and musculoskeletal systems. FF quantification is becoming established as a clinical and research tool, and understanding the underlying principles will be helpful to both imaging scientists and clinicians.

The radiology of bone has been transformed by magnetic resonance imaging, which has the ability to interrogate bone's complex architecture and physiology. New techniques provide information about both the macrostructure and microstructure of bone ranging from micrometre detail to the whole skeleton. Furthermore functional information about bone physiology can be used to detect disease early before structural changes occur. The future of bone imaging is in quantifying the anatomical and functional information to diagnose and monitor disease more precisely. This review explores the state of the art in quantitative MRI bone imaging., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Purpose: To evaluate proton density fat fraction (PDFF) and R2* as markers of bone marrow composition and structure in inflamed bone in patients with spondyloarthritis., Methods: Phantoms containing fat, water, and trabecular bone were constructed with proton density fat fraction (PDFF) and bone mineral density (BMD) values matching those expected in healthy bone marrow and disease states, and scanned using chemical shift-encoded MRI (CSE-MRI) at 3T. Measured PDFF and R2* values in phantoms were compared with reference FF and BMD values. Eight spondyloarthritis patients and 10 controls underwent CSE-MRI of the sacroiliac joints. PDFF and R2* in areas of inflamed bone and fat metaplasia in patients were compared with normal bone marrow in controls., Results: In phantoms, PDFF measurements were accurate over the full range of PDFF and BMD values. R2* measurements were positively associated with BMD but also were influenced by variations in PDFF. In patients, PDFF was reduced in areas of inflammation and increased in fat metaplasia compared to normal marrow. R2* measurements were significantly reduced in areas of fat metaplasia., Conclusion: PDFF measurements reflect changes in marrow composition in areas of active inflammation and structural damage and could be used for disease monitoring in spondyloarthritis. R2* measurements may provide additional information bone mineral density but also are influenced by fat content. Magn Reson Med 79:1031-1042, 2018. © 2017 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited., (© 2017 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine.)

Objective: To determine which of four Dixon image types [in-phase (IP), out-of-phase (OP), fat only (FO) and water-only (WO)] is most sensitive for detecting multiple myeloma (MM) focal lesions on whole body MRI (WB-MRI) images., Methods: Thirty patients with clinically-suspected MM underwent WB-MRI at 3 Tesla. Unenhanced IP, OP, FO and WO Dixon images were generated and read by four radiologists. On each image type, each radiologist identified and labelled all visible myeloma lesions in the bony pelvis. Each identified lesion was compared with a reference standard consisting of pre- and post-contrast Dixon and diffusion weighted imaging (read by a further consultant radiologist) to determine whether the lesion was truly positive. Lesion count, true positives, sensitivity, and positive predictive value were compared across the four Dixon image types., Results: Lesion count, true positives, sensitivity and confidence scores were all significantly higher on FO images than on IP images (p>0.05)., Discussion: FO images are more sensitive than other Dixon image types for MM focal lesions, and should be preferentially read by radiologists to improve diagnostic accuracy and reporting efficiency.

Objective: The aim was to evaluate diffusion-weighted imaging (DWI) as a tool for measuring treatment response in adolescents with enthesitis-related arthropathy (ERA)., Methods: Twenty-two adolescents with ERA underwent routine MRI and DWI before and after TNF inhibitor therapy. Each patient's images were visually scored by two radiologists using the Spondyloarthritis Research Consortium of Canada system, and sacroiliac joint apparent diffusion coefficient (ADC) and normalized ADC (nADC) were measured for each patient. Therapeutic clinical response was defined as an improvement of ⩾ 30% physician global assessment and radiological response defined as ⩾ 2.5-point reduction in Spondyloarthritis Research Consortium of Canada score. We compared ADC and nADC changes in responders and non-responders using the Mann-Whitney-Wilcoxon test., Results: For both radiological and clinical definitions of response, reductions in ADC and nADC after treatment were greater in responders than in non-responders (for radiological response: ADC: P < 0.01; nADC: P = 0.055; for clinical response: ADC: P = 0.33; nADC: P = 0.089). ADC and nADC could predict radiological response with a high level of sensitivity and specificity and were moderately sensitive and specific predictors of clinical response (the area under the receiver operating characteristic curves were as follows: ADC: 0.97, nADC: 0.82 for radiological response; and ADC: 0.67, nADC: 0.78 for clinical response)., Conclusion: DWI measurements reflect the response to TNF inhibitor treatment in ERA patients with sacroiliitis as defined using radiological criteria and may also reflect clinical response. DWI is more objective than visual scoring and has the potential to be automated. ADC/nADC could be used as biomarkers of sacroiliitis in the clinic and in clinical trials., (© The Author 2016. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Objective: To determine the extent to which inflammation of the sacroiliac joints (SIJs) and apophyseal joints (AJs) changes concordantly after treatment in enthesitis-related arthritis (ERA)., Methods: A retrospective study was performed with institutional review board approval. 31 young patients with ERA who had been scanned between March 2009 and November 2014 were included. All patients had post-contrast imaging of the SIJs and lumbar spine and short tau inversion-recovery (STIR) images of the SIJs. The severity of sacroiliitis was scored using a modification of an established technique, and inflammation of the AJs was evaluated using a recently described grading system. The changes in SIJ and AJ scores after treatment were classified as either concordant or discordant, and the proportion of scan pairs in these groups was recorded. In addition, the correlation between change in SIJ STIR score (Δnfla) and change in AJ score (ΔAJ) was assessed using Spearman's correlation coefficient., Results: Of a total of 43 scan pairs, the changes in inflammation were concordant in 16 scan pairs and discordant in 27 scan pairs. There was no significant correlation between Δnfla and ΔAJ (R = 0.14, p = 0.37)., Conclusion: Inflammatory changes in the SIJs and AJs are often discordant. This may be a reason why patients experience ongoing back pain despite apparent improvement in one or the other site., Advances in Knowledge: Inflammation may behave differently at different anatomical sites. The SIJs and AJs should both be imaged in patients with ERA with back pain.

Purpose: To determine the extent to which apparent diffusion coefficient (ADC) values vary with skeletal maturity in adolescent joints., Materials and Methods: A retrospective study was performed with Institutional Review Board (IRB) approval. We used a picture archiving and communication system (PACS) search to identify and recruit all adolescents who had undergone 1.5T magnetic resonance imaging (MRI) of the sacroiliac joints (SIJs) between January 2010 and June 2015, and had no evidence of sacroiliitis and normal inflammatory markers. In all, 55 individuals were assessed. For each patient, coronal and sagittal images of the sacrum were visually analyzed to determine sacral maturity. Patients were divided into three groups depending on the degree of fusion of the sacral segmental apophyses: "Fused," "Partial," and "Unfused." For each group, SIJ ADC was measured using a linear region-of-interest technique., Results: Mean ADC values were 690 × 10(-6) mm(2) /s in the fused group, 720 × 10(-6) mm(2) /s in the partial group, and 842 × 10(-6) mm(2) /s in the unfused group. ADC values were significantly higher in the unfused group than in the fused group (P = 0.046). ADC values were also higher in unfused subjects than partially fused subjects (P = 0.074)., Conclusion: Joint ADC values are higher in skeletally immature (unfused) patients than in skeletally more mature (fused) patients. ADC values measured in the unfused group overlap with those previously reported in sacroiliitis. These results suggest that ADC measurements in adolescent joints must be interpreted in light of joint maturity. Joint immaturity may lead to misdiagnosis of sacroiliitis, since immature juxta-articular bone may appear similar to inflammation. J. Magn. Reson. Imaging 2016. J. Magn. Reson. Imaging 2016;44:556-564., (© 2016 The Authors Journal of Magnetic Resonance Imaging published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine.)

Background: Sentinel lymph node biopsy (SLNB) in melanoma is currently performed using the standard dual technique (radioisotope and blue dye). The magnetic technique is non-radioactive and provides a brown color change in the sentinel lymph node (SLN) through an intradermal injection of a magnetic tracer, and utilizes a handheld magnetometer. The MELAMAG Trial compared the magnetic technique with the standard technique for SLNB in melanoma., Methods: Clinically node-negative patients with primary cutaneous melanoma were recruited from four centers. SLNB was undertaken after intradermal administration of both the standard (blue dye and radioisotope) and magnetic tracers. The SLN identification rate per patient, with the two techniques, was compared., Results: A total of 133 patients were recruited, 129 of which were available for final analysis. The sentinel node identification rate was 97.7 % (126/129) with the standard technique and 95.3 % (123/129) with the magnetic technique [2.3 % difference; 95 % upper confidence limit (CL) 6.4; 5.4 % discordance]. With radioisotope alone, the SLN identification rate was 95.3 % (123/129), as with the magnetic technique (0 % difference; 95 % upper CL 4.5; 7.8 % discordance). The lymph node retrieval rate was 1.99 nodes per patient overall, 1.78 with the standard technique and 1.87 with the magnetic technique., Conclusions: The magnetic technique is feasible for SLNB in melanoma with a high SLN identification rate, but is associated with skin staining. When compared with the standard dual technique, it did not reach our predefined non-inferiority margin.

Objective: To investigate the use of a quantitative diffusion-weighted imaging (DWI) tool for measuring inflammation of the sacroiliac joints (SIJs) in enthesitis-related arthritis (ERA)., Methods: A retrospective study was performed with institutional review board approval. Subjects were adolescents who had undergone MRI of the SIJs since January 2010. 10 patients with a clinical diagnosis of ERA and 10 controls with a clinical diagnosis of mechanical back pain were assessed. Axial T1 weighted, short tau inversion recovery (STIR) and DWI (b-values 0, 50, 100, 300 and 600 mm(2) s(-1)) images were acquired. Apparent diffusion coefficient (ADC) maps were generated using a monoexponential fit. On each of four slices, two to three linear regions-of-interest were placed on each joint. Normalized ADC (nADC) values were defined as joint ADC divided by a reference ADC derived from normal sacral bone. STIR images were scored using a modification of an established technique. The correlation between nADC values and STIR scores was evaluated using Spearman's rank correlation., Results: Mean nADC values were significantly higher in cases than in controls (p = 0.0015). There was a strong correlation between STIR scores and nADC values (R = 0.85)., Conclusion: ADC values are significantly increased in inflamed SIJs compared with controls. There is a good correlation between this diffusion-based method and STIR scores of inflammation., Advances in Knowledge: We have described and provisionally validated a method for quantifying the severity of inflammation in the SIJs in ERA using ADC measurements. This method is quick, is reproducible and could potentially be automated.

Objective: Sentinel lymph node biopsy (SLNB) with a superparamagnetic iron oxide (SPIO) tracer was shown to be non-inferior to the standard combined technique in the SentiMAG Multicentre Trial. The MRI subprotocol of this trial aimed to develop a magnetic alternative for pre-operative lymphoscintigraphy (LS). We evaluated the feasibility of using MRI following the administration of magnetic tracer for pre-operative localization of sentinel lymph nodes (SLNs) and its potential for non-invasive identification of lymph node (LN) metastases., Methods: Patients with breast cancer scheduled to undergo SLNB were recruited for pre-operative LS, single photon emission CT (SPECT)-CT and SPIO MRI. T1 weighted turbo spin echo and T2 weighted gradient echo sequences were used before and after interstitial injection of magnetic tracer into the breast. SLNs on MRI were defined as LNs with signal drop and direct lymphatic drainage from the injection site. LNs showing inhomogeneous SPIO uptake were classified as metastatic. During surgery, a handheld magnetometer was used for SLNB. Blue or radioactive nodes were also excised. The number of SLNs and MR assessment of metastatic involvement were compared with surgical and histological outcomes., Results: 11 patients were recruited. SPIO MRI successfully identified SLNs in 10 of 11 patients vs 11 of 11 patients with LS/SPECT-CT. One patient had metastatic involvement of four LNs, and this was identified in one node on pre-operative MRI., Conclusion: SPIO MRI is a feasible technique for pre-operative localization of SLNs and, in combination with intraoperative use of a handheld magnetometer, provides an entirely radioisotope-free technique for SLNB. Further research is needed for the evaluation of MRI characterization of LN involvement using subcutaneous injection of magnetic tracer., Advances in Knowledge: This study is the first to demonstrate that an interstitially administered magnetic tracer can be used both for pre-operative imaging and intraoperative SLNB, with equal performance to imaging and localization with radioisotopes.

Objective: To examine the management and long-term outcomes of transverse vaginal septae., Design: Observational study with cross-sectional and retrospective arms., Setting: Tertiary referral centre specialising in Müllerian anomalies., Population: Forty-six girls and women with a transverse vaginal septum., Methods: Data from medical records of all cases (1998-2013) of transverse vaginal septae were collected and reviewed. Patients over 16 years of age also completed a questionnaire., Main Outcome Measures: Presentation, examination findings, investigations, surgery, and long-term reproductive outcomes., Results: The septae in the study were described as follows: 61% (95% CI 0.46-0.74) were imperforate, and presented with obstructed menstruation; 39% (95% CI 0.26-0.54) were perforate, and presented with a variety of concerns; 72% (95% CI 0.57-0.83) were low, 22% (95% CI 0.12-0.36) were mid-vaginal, and 6% (95% CI 0.02-0.18) were high; 33% were managed via an abdominoperineal approach, 59% were managed via a vaginal approach, and 6% had laparoscopic resection (one patient did not have surgery); 11% (95% CI 0.05-0.23) of patients presented with reobstruction, all following abdominoperineal vaginoplasty; 7% presented with vaginal stenosis, two following vaginal resection and one following the abdominoperineal approach; 61% of questionnaires were returned. These results showed that 22/23 patients were menstruating and one had a hysterectomy, 74% had been sexually active, 35% had dyspareunia, and 36% complained of dysmenorrhoea. There were seven pregnancies, with one termination and six live births, all following the vaginal excision of a transverse vaginal septum., Conclusions: Transverse vaginal septae resected vaginally or laparoscopically have low complication rates and good long-term outcomes. Complex septae require more extensive surgery, with an increased risk of complications., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Background: The SentiMAG Multicentre Trial evaluated a new magnetic technique for sentinel lymph node biopsy (SLNB) against the standard (radioisotope and blue dye or radioisotope alone). The magnetic technique does not use radiation and provides both a color change (brown dye) and a handheld probe for node localization. The primary end point of this trial was defined as the proportion of sentinel nodes detected with each technique (identification rate)., Methods: A total of 160 women with breast cancer scheduled for SLNB, who were clinically and radiologically node negative, were recruited from seven centers in the United Kingdom and The Netherlands. SLNB was undertaken after administration of both the magnetic and standard tracers (radioisotope with or without blue dye)., Results: A total of 170 SLNB procedures were undertaken on 161 patients, and 1 patient was excluded, leaving 160 patients for further analysis. The identification rate was 95.0 % (152 of 160) with the standard technique and 94.4 % (151 of 160) with the magnetic technique (0.6 % difference; 95 % upper confidence limit 4.4 %; 6.9 % discordance). Of the 22 % (35 of 160) of patients with lymph node involvement, 16 % (25 of 160) had at least 1 macrometastasis, and 6 % (10 of 160) had at least a micrometastasis. Another 2.5 % (4 of 160) had isolated tumor cells. Of 404 lymph nodes removed, 297 (74 %) were true sentinel nodes. The lymph node retrieval rate was 2.5 nodes per patient overall, 1.9 nodes per patient with the standard technique, and 2.0 nodes per patient with the magnetic technique., Conclusions: The magnetic technique is a feasible technique for SLNB, with an identification rate that is not inferior to the standard technique.