Totally Rad

[Fwd: Aneurysms -- All You Need to Know]

2009-03-26T15:08:00.000-07:00

Concurrent Chemotherapy and Radiotherapy for Head and Neck Cancer

2009-03-24T11:30:00.001-07:00

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Concurrent Chemotherapy and Radiotherapy for Head and Neck Cancer

The rationale and evidence supporting the use of concurrent chemotherapy and radiation therapy in the management of locally advanced head and neck cancers are presented in this article.

Expert Review of Anticancer Therapy

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Early Detection of Ovarian Cancer Looks Feasible, But More Data Needed

2009-03-21T01:14:00.001-07:00

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Early Detection of Ovarian Cancer Looks Feasible, But More Data Needed

via Medscape Radiology Headlines on 3/20/09

Multimodal screening with CA125 plus transvaginal ultrasound and screening with transvaginal ultrasound alone have shown efficacy in detecting ovarian cancer at an early stage. It is too early, however, to make any screening recommendations for the general population.
Medscape Medical News

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ISC 2009: Rupture Risk Higher in Familial vs Sporadic Aneurysms

2009-03-13T16:50:00.001-07:00

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ISC 2009: Rupture Risk Higher in Familial vs Sporadic Aneurysms

via Medscape Radiology Headlines on 3/13/09

Small unruptured aneurysms in those with a family history of aneurysm have a higher risk of rupture than similar-sized sporadic aneurysms, something that should be considered in the management of these patients, researchers say.
Medscape Medical News

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High-Resolution Ultrasonography in Evaluating Peripheral Nerve Entrapment an...

2009-03-12T23:26:00.001-07:00

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High-Resolution Ultrasonography in Evaluating Peripheral Nerve Entrapment and Trauma

via Medscape Radiology Headlines on 3/11/09

In this article, the authors discuss the basic technical considerations for using ultrasoniography in peripheral nerve assessment, and some of the clinical applications are illustrated.
Neurosurgical Focus

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Overtreating Chronic Back Pain: Time to Back Off?

2009-03-10T22:19:00.001-07:00

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Overtreating Chronic Back Pain: Time to Back Off?

via Medscape Radiology Headlines on 3/10/09

Could a chronic disease model for managing chronic back pain solve this problem?
Journal of the American Board of Family Medicine

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Colonoscopy Is Preferred Test for Colorectal Cancer Screenings, Says America...

2009-03-10T01:18:00.001-07:00

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Colonoscopy Is Preferred Test for Colorectal Cancer Screenings, Says American College of Gastroenterology

via Medscape Radiology Headlines on 3/9/09

Rather than discussing various options, clinicians should recommend colonoscopy for colorectal cancer screening, say new guidelines.
Medscape Medical News

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What Is the Current Role of CT Urography and MR Urography in the Evaluation ...

2009-03-07T13:41:00.011-08:00

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What Is the Current Role of CT Urography and MR Urography in the Evaluation of the Urinary Tract?

via Most-Read Full-Text Articles by Stuart G. Silverman, John R. Leyendecker, E. Stephen Amis Jr on 2/1/09

Stuart G. Silverman, John R. Leyendecker, E. Stephen Amis Jr
Feb 1, 2009; 250:309-323
Controversies

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Nephrogenic Systemic Fibrosis: Incidence, Associations, and Effect of Risk F...

2009-03-07T13:41:00.009-08:00

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Nephrogenic Systemic Fibrosis: Incidence, Associations, and Effect of Risk Factor Assessment--Report of 33 Cases

via Most-Read Full-Text Articles by Javier Perez-Rodriguez, Shenghan Lai, Benjamin D. Ehst, Derek M. Fine, David A. Bluemke on 2/1/09

Javier Perez-Rodriguez, Shenghan Lai, Benjamin D. Ehst, Derek M. Fine, David A. Bluemke
Feb 1, 2009; 250:371-377
Contrast Media

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Case 142: Susac Syndrome

2009-03-07T13:41:00.007-08:00

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Case 142: Susac Syndrome

via Most-Read Full-Text Articles by Mustafa Kemal Demir on 2/1/09

Mustafa Kemal Demir
Feb 1, 2009; 250:598-602
Diagnosis Please

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Acute Appendicitis in Young Children: Cost-effectiveness of US versus CT in ...

2009-03-07T13:41:00.005-08:00

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Acute Appendicitis in Young Children: Cost-effectiveness of US versus CT in Diagnosis--A Markov Decision Analytic Model

via Most-Read Full-Text Articles by Michael J. Wan, Murray Krahn, Wendy J. Ungar, Edona Caku, Lillian Sung, L. Santiago Medina, Andrea S. Doria on 12/1/08

Michael J. Wan, Murray Krahn, Wendy J. Ungar, Edona Caku, Lillian Sung, L. Santiago Medina, Andrea S. Doria
Dec 1, 2008; 250:378-386
Evidence-based Practice

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Suspected Appendicitis in Children: Diagnostic Importance of Normal Abdomino...

2009-03-07T13:41:00.003-08:00

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Suspected Appendicitis in Children: Diagnostic Importance of Normal Abdominopelvic CT Findings with Nonvisualized Appendix

via Most-Read Full-Text Articles by Kimberly Garcia, Marta Hernanz-Schulman, Debbie Lee Bennett, Stephen E. Morrow, Chang Yu, J. Herman Kan on 2/1/09

Kimberly Garcia, Marta Hernanz-Schulman, Debbie Lee Bennett, Stephen E. Morrow, Chang Yu, J. Herman Kan
Feb 1, 2009; 250:531-537
Pediatric Imaging

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Distinguishing Adrenal Adenomas from Nonadenomas: Combined Use of Diagnostic...

2009-03-07T13:41:00.001-08:00

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Distinguishing Adrenal Adenomas from Nonadenomas: Combined Use of Diagnostic Parameters of Unenhanced and Short 5-minute Dynamic Enhanced CT Protocol

via Most-Read Full-Text Articles by Takuro Kamiyama, Yoshihiko Fukukura, Tomohide Yoneyama, Koji Takumi, Masayuki Nakajo on 12/1/08

Takuro Kamiyama, Yoshihiko Fukukura, Tomohide Yoneyama, Koji Takumi, Masayuki Nakajo
Dec 1, 2008; 250:474-481
Genitourinary Imaging

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Forget the Diffusion--Do We Need T2-weighted MR Images to Detect Early Centr...

2009-03-07T13:40:00.003-08:00

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Forget the Diffusion--Do We Need T2-weighted MR Images to Detect Early Central Nervous System Injury?

via Most-Read Full-Text Articles by David B. Hackney on 2/1/09

David B. Hackney
Feb 1, 2009; 250:303-304
Science to Practice

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CT Venography: A Necessary Adjunct to CT Pulmonary Angiography or a Waste of...

2009-03-07T13:40:00.001-08:00

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CT Venography: A Necessary Adjunct to CT Pulmonary Angiography or a Waste of Time, Money, and Radiation?

via Most-Read Full-Text Articles by Lawrence R. Goodman, H. Dirk Sostman, Paul D. Stein, Pamela K. Woodard on 2/1/09

Lawrence R. Goodman, H. Dirk Sostman, Paul D. Stein, Pamela K. Woodard
Feb 1, 2009; 250:327-330

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Benign Hepatic Tumors and Iatrogenic Pseudotumors

2009-03-07T13:36:00.007-08:00

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Benign Hepatic Tumors and Iatrogenic Pseudotumors

via Most-Read Full-Text Articles by Stephan W. Anderson, Jonathan B. Kruskal, Robert A. Kane on 1/1/09

Stephan W. Anderson, Jonathan B. Kruskal, Robert A. Kane
Jan 1, 2009; 29:211-229
RSNA Education Exhibits

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Quality Initiatives * MR Imaging in Patients at Risk for Developing Nephroge...

2009-03-07T13:36:00.005-08:00

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Quality Initiatives * MR Imaging in Patients at Risk for Developing Nephrogenic Systemic Fibrosis: Protocols, Practices, and Imaging Techniques to Maximize Patient Safety

via Most-Read Full-Text Articles by Krishna Juluru, Jens Vogel-Claussen, Katarzyna J. Macura, Ihab R. Kamel, Alexander Steever, David A. Bluemke on 1/1/09

Krishna Juluru, Jens Vogel-Claussen, Katarzyna J. Macura, Ihab R. Kamel, Alexander Steever, David A. Bluemke
Jan 1, 2009; 29:9-22
Quality Initiatives

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Fat-containing Lesions of the Retroperitoneum: Radiologic-Pathologic Correla...

2009-03-07T13:36:00.003-08:00

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Fat-containing Lesions of the Retroperitoneum: Radiologic-Pathologic Correlation

via Most-Read Full-Text Articles by William D. Craig, Julie C. Fanburg-Smith, Leonard R. Henry, Ruben Guerrero, Joel H Barton on 1/1/09

William D. Craig, Julie C. Fanburg-Smith, Leonard R. Henry, Ruben Guerrero, Joel H Barton
Jan 1, 2009; 29:261-290
AFIP Archives

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Tumors in the Tracheobronchial Tree: CT and FDG PET Features

2009-03-07T13:36:00.001-08:00

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Tumors in the Tracheobronchial Tree: CT and FDG PET Features

via Most-Read Full-Text Articles by Chang Min Park, Jin Mo Goo, Hyun Ju Lee, Min A Kim, Chang Hyun Lee, Mi-Jin Kang on 1/1/09

Chang Min Park, Jin Mo Goo, Hyun Ju Lee, Min A Kim, Chang Hyun Lee, Mi-Jin Kang
Jan 1, 2009; 29:55-71
RSNA Education Exhibits

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Lesions of the Hypothalamus: MR Imaging Diagnostic Features

2009-03-07T13:35:00.003-08:00

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Lesions of the Hypothalamus: MR Imaging Diagnostic Features

via Most-Read Full-Text Articles by Sahar N. Saleem, Ahmed-Hesham M. Said, Donald H. Lee on 7/1/07

Sahar N. Saleem, Ahmed-Hesham M. Said, Donald H. Lee
Jul 1, 2007; 27:1087-1108
RSNA Education Exhibits

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Failed Endoscopic Sinus Surgery: Spectrum of CT Findings in the Frontal Recess

2009-03-07T13:35:00.001-08:00

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Failed Endoscopic Sinus Surgery: Spectrum of CT Findings in the Frontal Recess

via Most-Read Full-Text Articles by Benjamin Y. Huang, Kristen M. Lloyd, John M. DelGaudio, Eric Jablonowski, Patricia A. Hudgins on 1/1/09

Benjamin Y. Huang, Kristen M. Lloyd, John M. DelGaudio, Eric Jablonowski, Patricia A. Hudgins
Jan 1, 2009; 29:177-195
RSNA Education Exhibits

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Women at High Risk for Breast Cancer - What the Primary Care Provider Needs ...

2009-03-04T22:33:00.001-08:00

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Women at High Risk for Breast Cancer - What the Primary Care Provider Needs to Know

via Medscape Radiology Headlines on 3/4/09

It is important for the primary care provider to not only screen for breast cancers, but also be able to identify women at higher risks for breast cancer.
Journal of the American Board of Family Medicine

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Parapelvic cysts: appearance on CT and sonography

2009-03-04T22:19:00.003-08:00

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Parapelvic cysts: appearance on CT and sonography

via Most-Read Full-Text Articles by H Hidalgo, NR Dunnick, ER Rosenberg, PC Ram, M Korobkin on 4/1/82

H Hidalgo, NR Dunnick, ER Rosenberg, PC Ram, M Korobkin
Apr 1, 1982; 138:667-671
Articles

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Popliteal Artery Entrapment Syndrome: Role of Imaging in the Diagnosis

2009-03-04T22:19:00.001-08:00

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Popliteal Artery Entrapment Syndrome: Role of Imaging in the Diagnosis

via Most-Read Full-Text Articles by Thanila A. Macedo, C. Michael Johnson, John W. Hallett Jr., Jerome F. Breen on 11/1/03

Thanila A. Macedo, C. Michael Johnson, John W. Hallett Jr., Jerome F. Breen
Nov 1, 2003; 181:1259-1265
Vascular Imaging

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Angiolipoma: a rare benign soft tissue tumor with a malignant arteriographic...

2009-03-04T22:18:00.001-08:00

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Angiolipoma: a rare benign soft tissue tumor with a malignant arteriographic appearance

via Most-Read Full-Text Articles by HJ Finberg, DC Levin on 4/1/77

HJ Finberg, DC Levin
Apr 1, 1977; 128:697-698
Articles

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MRI Helpful in Diagnosing Acute Appendicitis in Pregnant Patients

2009-03-04T01:23:00.001-08:00

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MRI Helpful in Diagnosing Acute Appendicitis in Pregnant Patients

via Medscape Radiology Headlines on 3/3/09

Magnetic resonance imaging has the potential to minimize and even avoid exposure to radiation associated with computed tomography.
Medscape Medical News

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Imaging the Painful Osteoarthritic Knee Joint: What Have We Learned?

2009-03-03T02:06:00.001-08:00

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Imaging the Painful Osteoarthritic Knee Joint: What Have We Learned?

via Medscape Radiology Headlines on 3/2/09

MRI may detect osteoarthritis of the knee at earlier stages compared with plain x-rays, and may give insight into the structures affected.
Nature Clinical Practice Rheumatology

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[Musculoskeletal Imaging] Comparison of 1.5- and 3.0-T MR Imaging for Evalua...

2009-02-24T22:47:00.003-08:00

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[Musculoskeletal Imaging] Comparison of 1.5- and 3.0-T MR Imaging for Evaluating the Articular Cartilage of the Knee Joint

via Radiology Musculoskeletal Imaging by Kijowski, R., Blankenbaker, D. G., Davis, K. W., Shinki, K., Kaplan, L. D., De Smet, A. A. on 2/24/09

Purpose: To retrospectively compare the diagnostic performance of 1.5- and 3.0-T magnetic resonance (MR) imaging protocols for evaluating the articular cartilage of the knee joint in symptomatic patients.

Materials and Methods: This HIPAA-compliant study was performed with a waiver of informed consent from the institutional review board. The study group consisted of 200 symptomatic patients undergoing MR examination of the knee at 1.5 T (61 men, 39 women; mean age, 38.9 years) or 3.0 T (52 men, 48 women; mean age, 39.1 years), who also underwent subsequent arthroscopic knee surgery. All MR examinations consisted of multiplanar fast spin-echo sequences with similar tissue contrast at 1.5 and 3.0 T. All articular surfaces were graded at arthroscopy by using the Noyes classification system. Three musculoskeletal radiologists retrospectively and independently graded all articular surfaces seen at MR imaging by using a similar classification system. The sensitivity, specificity, and accuracy of the 1.5- and 3.0-T MR protocols for detecting cartilage lesions were determined by using arthroscopy as the reference standard. The z test was used to compare sensitivity, specificity, and accuracy values at 1.5 and 3.0 T.

Results: For all readers combined, the respective sensitivity, specificity, and accuracy of MR imaging for detecting cartilage lesions were 69.3%, 78.0%, and 74.5% at 1.5 T (n = 241) and 70.5%, 85.9%, and 80.1% at 3.0 T (n = 226). The MR imaging protocol had significantly higher specificity and accuracy (P < .05) but not higher sensitivity (P = .73) for detecting cartilage lesions at 3.0 T than at 1.5 T.

Conclusion: A 3.0-T MR protocol has improved diagnostic performance for evaluating the articular cartilage of the knee joint in symptomatic patients when compared with a 1.5-T protocol.

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[Musculoskeletal Imaging] Pain and Other Side Effects after MR Arthrography:...

2009-02-24T22:47:00.001-08:00

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[Musculoskeletal Imaging] Pain and Other Side Effects after MR Arthrography: Prospective Evaluation in 1085 Patients

via Radiology Musculoskeletal Imaging by Saupe, N., Zanetti, M., Pfirrmann, C. W. A., Wels, T., Schwenke, C., Hodler, J. on 2/24/09

Purpose: To prospectively evaluate pain and other side effects after magnetic resonance (MR) arthrography.

Materials and Methods: Institutional review board approval and patient informed consent were obtained. MR arthrography was performed in 1085 patients. In 1011 patients, 2 mmol/L gadopentetate dimeglumine was injected. In patients whose wrists were examined, 5 mmol/L gadoterate dimeglumine was injected. Pain was measured directly after injection, 4 hours after injection, 1 day [18–30 hours] after injection, and 1 week [6–8 days] after injection and compared with pain at baseline (before contrast material was injected). A visual analogue scale or verbal rating scale (score range, 0–10) was used to measure pain. When increased pain persisted at the end of the observation period, additional assessment was performed to exclude infection. Evaluated factors with a potential effect on pain were time after injection, joint type, contrast agent volume, patient age and sex, and radiologist experience. Repeated measures analysis of variance was used.

Results: Mean pain increase was most pronounced 4 hours after injection (P < .0001). This increase was most pronounced in the hip, followed by the elbow, knee, wrist, ankle, and shoulder. (Differences between joints were not significant [P = .26].) Pain scores returned to baseline levels 1 week after injection. Patients younger than 30 years had more pronounced pain than did patients in other age groups at all time points (P = .044). Joint type, contrast agent volume (P = .44), patient sex (P = .29), and radiologist experience (P = .10) did not significantly affect pain scores. No patient had infection or any other severe side effect. Besides joint pain, minor side effects included pressure, headache, muscle ache, swollen hand, fatigue, vertigo, increased blood glucose level, and pruritus.

Conclusion: MR arthrography temporarily increases joint-related pain. Such pain depends on patient age but not on joint type, contrast material volume, patient sex, or radiologist experience.

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Diagnosis and Management of Atherosclerotic Renal Artery Stenosis: Improving Patient Selection and Outcomes

2009-02-23T22:09:00.001-08:00

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Diagnosis and Management of Atherosclerotic Renal Artery Stenosis: Improving Patient Selection and Outcomes

Atherosclerotic renal artery stenosis is associated with a high rate of mortality by the time that it leads to end-stage renal disease. The current review highlights how to diagnose and treat renal artery stenosis before it is too late.
Nature Clinical Practice Cardiovascular Medicine

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Hyperextension Cervical Spine Injuries and Traumatic Central Cord Syndrome

2009-02-20T19:20:00.003-08:00

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Hyperextension Cervical Spine Injuries and Traumatic Central Cord Syndrome

This article describes the symptoms of traumatic cervical central cord syndrome - the most frequently encountered incomplete spinal cord injury.

Neurosurgical Focus

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Recurrence Rate of Lumbar Disc Herniation After Open Discectomy in Active Young Men

2009-02-20T19:20:00.001-08:00

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Recurrence Rate of Lumbar Disc Herniation After Open Discectomy in Active Young Men

A higher incidence of disc herniation is seen in young adults. This study evaluated the recurrence rate of lumbar disc herniation specifically in active young men.

Spine

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Indications for Breast MRI in the Patient With Newly Diagnosed Breast Cancer

2009-02-17T00:41:00.001-08:00

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Indications for Breast MRI in the Patient With Newly Diagnosed Breast Cancer

via Medscape Radiology Headlines on 2/16/09

Breast MRI has improved sensitivity for diagnosing occult cancers among women with breast cancer, and it has been used as an adjunct to screening mammography. The current study examines the clinical evidence in regard to the utility of breast MRI.
Journal of the National Comprehensive Cancer Network

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PET and PET-CT Imaging of Gynecological Malignancies: Present Role and Future Promise

2009-02-13T12:57:00.001-08:00

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PET and PET-CT Imaging of Gynecological Malignancies: Present Role and Future Promise

Gynecological malignancy management is increasingly being aided by the use of PET and PET-CT scanning for detection and forcasting a prognosis. Authors review the evidence to date.

Expert Review of Anticancer Therapy

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Duplex Scan in Patients With Clinical Suspicion of Deep Venous Thrombosis

2009-02-10T23:48:00.001-08:00

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Duplex Scan in Patients With Clinical Suspicion of Deep Venous Thrombosis

How useful is the duplex scan in identifying deep venous thrombosis (DVT)?

Cardiovascular Ultrasound

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Imaging of Fatty Tumors: Distinction of Lipoma and Well-differentiated Liposarcoma

2009-02-10T23:33:00.005-08:00

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Imaging of Fatty Tumors: Distinction of Lipoma and Well-differentiated Liposarcoma

Mark J. Kransdorf, Laura W. Bancroft, Jeffrey J. Peterson, Mark D. Murphey, William C. Foster, H. Thomas Temple
Jul 1, 2002; 224:99-104
Musculoskeletal Imaging

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Double-Contrast Upper Gastrointestinal Radiography: A Pattern Approach for Diseases of the Stomach

2009-02-10T23:33:00.003-08:00

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Double-Contrast Upper Gastrointestinal Radiography: A Pattern Approach for Diseases of the Stomach

Stephen E. Rubesin, Marc S. Levine, Igor Laufer
Jan 1, 2008; 246:33-48
Review for Residents

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Superior Semicircular Canal Dehiscence Syndrome and Multi-Detector Row CT

2009-02-10T23:33:00.001-08:00

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Superior Semicircular Canal Dehiscence Syndrome and Multi-Detector Row CT

Hugh D. Curtin
Feb 1, 2003; 226:312-314
Editorials

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MR Imaging Insights into Skeletal Maturation: What Is Normal?

2009-02-10T23:32:00.001-08:00

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MR Imaging Insights into Skeletal Maturation: What Is Normal?

Tal Laor, Diego Jaramillo
Jan 1, 2009; 250:28-38

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Nonspecific Interstitial Pneumonia: Radiologic, Clinical, and Pathologic Considerations

2009-02-10T23:29:00.001-08:00

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Nonspecific Interstitial Pneumonia: Radiologic, Clinical, and Pathologic Considerations

Seth J. Kligerman, Steve Groshong, Kevin K Brown, David A. Lynch
Jan 1, 2009; 29:73-87
RSNA Education Exhibits

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Intraductal Papillary Mucinous Tumor of the Pancreas: A Pictorial Essay

2009-02-10T23:28:00.004-08:00

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Intraductal Papillary Mucinous Tumor of the Pancreas: A Pictorial Essay

Carlo Procacci, Alec J. Megibow, Giovanni Carbognin, Alessandro Guarise, Elide Spoto, Carlo Biasiutti, Gian Franco Pistolesi
Nov 1, 1999; 19:1447-1463
Scientific Exhibits

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From the Archives of the AFIP: Pyelonephritis: Radiologic-Pathologic Review

2009-02-10T23:28:00.003-08:00

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From the Archives of the AFIP: Pyelonephritis: Radiologic-Pathologic Review

William D. Craig, Brent J. Wagner, Mark D. Travis
Jan 1, 2008; 28:255-276
AFIP Archives

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Ovarian Teratomas: Tumor Types and Imaging Characteristics

2009-02-10T23:28:00.001-08:00

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Ovarian Teratomas: Tumor Types and Imaging Characteristics

Eric K. Outwater, Evan S. Siegelman, Jennifer L. Hunt
Mar 1, 2001; 21:475-490
RSNA Education Exhibits

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Diseases of the Hepatopulmonary Axis

2009-02-10T23:27:00.001-08:00

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Diseases of the Hepatopulmonary Axis

Cris A. Meyer, Charles S. White, Kenneth E. Sherman
May 1, 2000; 20:687-698
Scientific Exhibits

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Cardiac CT Angiography and Radiation Dose

2009-02-08T14:03:00.001-08:00

From Heartwire — a professional news service of WebMD

February 6, 2009 — A new American Heart Association (AHA) science advisory says there are no data to support the use of cardiac computed tomography angiography (CCTA) in asymptomatic, low-risk patients, so the albeit-small risk of cancer from radiation currently outweighs the lack of any demonstrable benefit in such people [1]. Dr Thomas C Gerber (Mayo Clinic, Jacksonville, FL) and colleagues discuss the subject in a paper published online February 2, 2009, in Circulation.

The advisory comes as a newly published trial in the February 4, 2009, issue of the Journal of the American Medical Association (JAMA), the Prospective Multicenter Study on Radiation Dose Estimates of Cardiac CT Angiography in Daily Practice (PROTECTION 1), shows that there is great variation between centers in the amount of radiation emitted when a CCTA is performed and in the use of dose-saving strategies to reduce radiation exposure [2]. As reported by heartwire, Dr Jörg Hausleiter (German Heart Center, Munich, Germany) first presented the PROTECTION-1 findings at the American College of Cardiology (ACC) meeting in Chicago last year.

Gerber, who is also a coauthor on the JAMA paper, told heartwire: "The main message of our advisory is that it's important to match the right type of test to the right type of patient. CCTA is not the right test for asymptomatic, low-risk patients, because you have the very small risk of potential cancer on the one hand and no outcome data to suggest any benefit on the other. However, if you move up the ladder to intermediate-risk patients, there is no question that CCTA (or nuclear perfusion stress tests) can be very helpful in those who have symptoms or at the very least are at high risk of heart artery disease."

Hausleiter has a slightly different take on the matter, however. He believes that CCTA may turn out to have benefits in asymptomatic patients, "but this needs to be proven." In the meantime, he agrees that "we are lacking data on the benefits of CCTA in asymptomatic patients."

Radiation Dose is Estimate, Link Between Dose and Cancer Unclear

Gerber said that an advisory is the lowest level of document, below guidelines or a statement, and indicates that there is "opinion" on a subject "but not a whole lot of data."

"This advisory is written for doctors, and we wanted to clarify a number of issues. First, doctors don't realize that the dose of radiation cannot really be measured — it's always a fairly crude estimate. What can be measured are certain parameters for CT-scanner radiation output, but this is not necessarily the same as the amount of radiation that the patient absorbs.

The second issue we wanted to clarify is the relationship between radiation dose and risk of cancer, which is the subject of ongoing debate. We're using a fairly conservative model and assuming a linear relationship from very high-dose levels — the kind of doses to which people were exposed in Hiroshima and Nagasaki — to the very low-dose levels we're talking about in medical imaging."

Assuming this linear relationship to be true, Gerber says the median radiation dose that was used until recently in CCTA — around 20 mSv — would potentially mean that one in 2000 exposed patients would develop a fatal cancer. However, he stresses that the median doses of radiation used in medical imaging are constantly being reduced due to new dose-saving technology.

"We are really trying to call on doctors to think about the potential risk vs the expected benefit for that patient. Although this is not what everyone wants to hear, we have no data yet that suggest that using CCTA in patients who have never had symptoms would be helpful in guiding management," he stresses.

Radiation Dose Not Affected by Procedure Volume, Center Expertise

In PROTECTION 1, which was observational and industry independent, Hausleiter and colleagues show a wide variation in radiation emitted by CCTA at the 50 sites examined worldwide. They analyzed 1965 procedures performed during one month, the majority of which were 64-slice. The main outcome was dose-length product (DLP) of CCTA; they also examined the use and efficacy of radiation dose-saving strategies (algorithms).

The DLP varied widely between study sites; it was used to estimate a median radiation dose of 12 mSv, which Hausleiter says is similar to that of an abdominal CT scan "that we order every day." He notes that the median dose given in the paper differs slightly from that reported at the ACC meeting last year — 15.4 mSv — due to a subsequent lowering of the conversion factor used to change the DLP to estimated radiation dose.

Independent factors associated with radiation dose included patient weight, absence of stable sinus rhythm, and varying use of dose-saving strategies.

Predictors for Estimated Radiation Dose in a Multivariate Linear Regression Analysis^a

Predictors	Effects (%)	p
Patient wt, 10-kg increase	5	< 0.001
Indication, noncoronary vs coronary	–1	0.31
Heart rhythm, nonsinus vs sinus	10	0.01
Heart rate, 10-bpm increase	1	0.98
Scan length, 1-cm increase	5	< 0.001
Automated exposure control	0	0.97
ECTCM^b	–25	< 0.001
Tube voltage 100 kV vs ≥ 120 kV or greater	–46	< 0.001
Sequential vs spiral scanning	–78	< 0.001
Site experience in CCTA, 12-mo increase	–1	0.03
Performed CCTAs/mo, 10-CCTA increase	0	0.03
64-slice CT system vs Siemens single-source 64^c
GE 64	97	< 0.001
Philips 64	11	< 0.001
Siemens dual-source 64	23	< 0.001
Toshiba 64	59	< 0.001

a. Predictors for radiation dose are presented as % change in DLP (mGy x cm).
b. Electrocardiographically controlled tube current modulation.
c. The Siemens single-source 64-slice CT system with the lowest median DLP in this study was used as a reference. The association with DLP is shown for the remaining four 64-slice systems within the linear regression analysis.

Hausleiter told heartwire he was surprised by the variation in radiation dose, both by site and by the machine employed. "We cannot explain the differences by expertise or by volume, so there is still potential to reduce the dose at a lot of sites," he notes.

But Gerber said he was not at all surprised by these findings. "There are a whole lot of confounders in there that are difficult to account for, and we shouldn't use a one-size-fits-all approach to protocols for CTs." For example, he says, for very obese patients, the additional tissue means that operators have to double the output of radiation to achieve the same quality of images, "so a center that images mainly obese patients will come out with a higher average reference level [of radiation] than a center that images mainly patients with normal body weight."

Another example is coronary artery bypass grafting, "where we have to image a much larger portion of the chest than if we are just imaging the heart, so that results in more radiation." And many dose-saving techniques cannot be used in patients with very fast or irregular heart rates, so "depending on the patients, some centers have no opportunity to use these algorithms."

Most Centers Used Dose-Saving Strategies, But Still Room for Improvement

Nevertheless, both Hausleiter and Gerber point out that the majority of the centers in PROTECTION 1 — over 70% — did use strategies for dose-saving. "This is a healthy message," says Gerber. "People are aware of these dose-saving algorithms, and they are being used." And this figure will likely improve, says Hausleiter, as people become more aware of dose-saving strategies and newer machines are employed that make greater use of such technologies.

In an editorial accompanying the JAMA paper [3], Dr Andrew J Einstein (Columbia University Medical Center, New York, NY) also applauds the fact that dose-reduction techniques were used in the majority of patients in PROTECTION 1 and says these results "should serve as a wake-up call to those cardiac CT labs that do not routinely use these methods."

Addressing specific dose-reduction strategies, Einstein says: "Given the strength of evidence supporting it, electrocardiographically controlled tube current modulation (ECTCM) should be widely applied; the evidence for sequential scanning is rapidly accumulating, and it should also be given serious consideration for appropriate patients. Low-voltage scanning should also be considered, perhaps especially for patients who are nonobese and at higher risk of radiation-associated cancer, such as children and young women."

Einstein adds that the variability between sites "that had not previously been appreciated" offers the potential to decrease radiation burden while maintaining image quality "by instituting quality-improvement programs to close the gap." This is something that high-volume centers can also learn from, he notes, pointing out the lack of association between procedure volume and dose.

Hausleiter told heartwire he expects to present further data at the ACC meeting this year, from PROTECTION 2 and 3, which are examining whether image quality is maintained despite the use of lower doses of radiation.

The study was supported solely by an unrestricted research grant from Deutsches Herzzentrum München, Klinik an der Technischen Universität, Munich, Germany. None of the participating physicians received any compensation for study participation. Dr. Hausleiter and coauthors Cynthia McCollough, PhD, and Stephan Achenbach, MD, have received research grants from Siemens Medical Systems unrelated to the current study. Dr. Achenbach was supported by a grant from the German Bundesministerium für Bildung und Forschung. The other study authors have disclosed no relevant financial relationships.

Dr. Einstein has served as a consultant for GE Healthcare, has received travel funding from GE Healthcare, INVIA, Philips Medical Systems, and Toshiba America Medical Systems, and has received support for previous research through a grant funded by Covidien and collaboration with employees of Siemens Medical Solutions. He is supported in part by a National Institutes of Health K12 Institutional Career Development Award.

Sources

Ionizing radiation in cardiac imaging. A science advisory from the American Heart Association Committee on Cardiac Imaging of the Council on Clinical Cardiology and Committee on Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radiology and Intervention. Circulation. 2009; DOI: 10.1161/CIRCULATIONAHA.108.191650. Available at: http://circ.ahajournals.org.
Hausleiter J, Meyer T, Hermann F, et al. Estimated radiation dose associated with cardiac CT angiography. JAMA. 2009;301:500-507.
Einstein AJ. Radiation protection of patients undergoing cardiac computed tomographic angiography. JAMA. 2009;301:545-547.

The complete contents of Heartwire, a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.

Clinical Context

Although CCTA is a useful diagnostic imaging modality to evaluate coronary artery disease, there is concern regarding potential risks associated with exposure to ionizing radiation. Selected indications include low-to-intermediate pretest probability for obstructive coronary artery disease and rapid evaluation of chest pain in patients seen in the emergency department.

Many clinicians may still be unaware of the magnitude of radiation exposure associated with CCTA and with the factors that independently contribute to radiation dose. This information is clearly needed to plan and implement strategies to minimize patient exposure to ionizing radiation without sacrificing image quality.

Study Highlights

The goals of this study were to estimate the radiation dose of CCTA in routine clinical practice, to evaluate the association of currently available strategies with dose reduction, and to identify the independent factors contributing to radiation dose.
This cross-sectional, international, multicenter, observational study took place at 50 study sites, including 21 university hospitals and 29 community hospitals.
Radiation dose was estimated for 1965 patients who underwent CCTA between February and December 2007.
Independent predictors associated with dose were determined by linear regression analysis.
The primary study endpoint was the DLP of CCTA.
Median DLP was 885 mGy x cm (interquartile range, 568 - 1259 mGy x cm). This corresponds to an estimated radiation dose of 12 mSv, which is comparable with 1.2 times the dose of an abdominal CT scan, more than twice that of invasive coronary angiography, or 600 chest radiographs.
There was a high variability in DLP between study sites (range of median DLPs per site, 331 - 2146 mGy x cm).
This 6-fold difference in DLP reflects the large variability in CCTA protocols, differences in CT system characteristics, and use of dose-reduction algorithms among individual study sites.
Independent clinical factors associated with radiation dose were patient weight (relative effect on DLP, 5%; 95% confidence interval [CI], 4% - 6%) and absence of stable sinus rhythm (relative effect on DLP, 10%; 95% CI, 2% - 19%).
Technical factors associated with radiation dose were scan length (relative effect on DLP, 5%; 95% CI, 4% - 6%), electrocardiographically controlled tube current modulation (relative effect on DLP, −25%; 95% CI, −23% to −28%; applied in 73% of patients), 100-kV tube voltage (relative effect on DLP, −46%; 95% CI, −42% to −51%; applied in 5% of patients), and sequential scanning (relative effect on DLP, −78%; 95% CI, −77% to −79%; applied in 6% of patients).
Site factors associated with radiation dose were experience in cardiac CT (relative effect on DLP, −1%; 95% CI, −1% to 0%), number of CCTAs per month (relative effect on DLP, 0%; 95% CI, 0% - 1%), and type of 64-slice CT system (for highest vs lowest dose system, relative effect on DLP, 97%; 95% CI, 88% - 106%).
In this study, algorithms for dose reduction were not associated with deteriorated diagnostic image quality, which may support their use in adequately selected patients.
The investigators concluded that median doses of CCTA varied significantly among study sites and CT systems. Despite the availability of effective strategies to reduce radiation dose, some strategies are infrequently used.
Limitations of the study include lack of universal standardization of the definition of tube current, and radiation dose associated with coronary calcium scoring not evaluated.

Pearls for Practice

Median estimated radiation dose for CCTA was 12 mSv, which is comparable with 1.2 times the dose of an abdominal CT, more than twice that of invasive coronary angiography, or 600 chest radiographs. There was a high variability in DLP among study sites, reflecting the large variability in CCTA protocols, differences in CT system characteristics, and use of dose-reduction algorithms among individual study sites.
Despite the availability of effective strategies to reduce radiation dose, some strategies are infrequently used. Independent factors associated with radiation dose were patient weight, absence of stable sinus rhythm, modifiable technical factors related to the scanning procedure, and site-specific factors.

total hip prosthesis loosening

2009-02-08T13:29:00.001-08:00

http://radiographics.rsnajnls.org/cgi/content/abstract/16/3/645

Prosthesis loosening

2009-02-08T13:19:00.001-08:00

From the RSNA refresher courses. Total hip arthroplasty: radiographic evaluation

BJ Manaster
Department of Radiology, University of Utah Medical Center, Salt Lake City 84132, USA.

Expected appearances of total hip arthroplasty vary according to type ofimplant, its method of fixation (cemented, porous coating for boneingrowth, press fit), and whether it is a revision. Cemented arthroplasticcomponents normally may show 1-2-mm-wide radiolucent zones at cementinterfaces. Definite loosening is diagnosed when progressive widening ofthe radiolucent zone, migration of a cemented component, or change inalignment is seen. In cementless arthroplasty, normal findings includecalcar resorption, radiolucent zones up to 2 mm in width, corticalthickening, periosteal reaction, endosteal sclerosis, and even subsidenceof the femoral component that stabilizes at less than 1 cm. The mostreliable radiographic signs of loosening in cementless arthroplasty areprogressive subsidence, migration, or tilt of the component. Becausesubsidence or change in alignment may be very subtle, serial radiographyand measurement are often required for diagnosis. Other signs that indicateloosening include bead shedding (in porous-coated prostheses), extensivecortical hypertrophy, endosteal bone bridging at the stem tip, endostealscalloping, and a radiolucent zone wider than 2 mm. In revisionarthroplasty, wide radiolucent zones and subsidence are common. Thediagnosis of revision failure is based on progressive widening of theradiolucent zones and change in component position after 12 months.

Aseptic loosening of prosthetic components is still the mostcommon cause for revision surgery. The mechanism of looseningcan be secondary to mechanical (stress) or biologic factors(degradation of the cement-bone or cementless interface resultingfrom the migration of wear particles). In both situations, thefailure can occur at the prosthesis-bone interface, prosthesis-cementinterface, or cement-bone interface. Progressive radiolucentareas greater than 1 mm at these interfaces are worrisome forprosthesis loosening. A radiolucent area greater than 2 mm inany of the three of acetabular zones (1 = superolateral, 2 =central, 3 = medial aspect of the bone–acetabular componentinterface), superior or medial migration of the cup, or changein inclination of the cup is indicative of loosening. The femoralcomponent–bone interface is divided into zones 1–7on the anteroposterior view (zones 1–3 at the lateralside proximal to distal, zone 4 at the tip of the femoral stem,zones 5–7 at the medial side distal to proximal) and intozones 1–7 on the lateral view (zones 1–3 at theanterior side proximal to distal, zone 4 at the tip of the femoralstem, and zones 5–7 at the posterior side distal to proximal)(Fig 18). The same rules regarding potential prosthesis looseningare used for both the prosthesis-bone interfaces of the femoralstem and those of the acetabular component (1–4,20,23,24).

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Figure 18. Diagram illustrates the radiographic zones for acetabular and femoral prostheses. The seven zones are explained in text. (Reprinted, with permission, from reference 4.)

Periprosthetic bone remodeling can occur after total hip arthroplastybecause of stress alterations in the proximal femur and pelvisafter prosthesis implantation. Proximal medial cortical boneloss and distal cortical thickening are commonly seen in thefemur. Bone remodeling changes seen around cementless acetabularcomponents are most commonly due to resorption of the subchondralplate and relative osteoporosis in zone 2 (1–4,20,23).

Focal osteolysis about the prosthesis was first recognized byCharney in the 1960s and was thought to be related to the cementused to anchor the prostheses. It has subsequently been recognizedthat any small particles (metal, cement, or polyethylene) canplay a role in initiating osteolysis. With the increased prevalenceof cementless fixation, polyethylene wear debris is the mostcommon cause for initiating osteolysis. Eccentric position ofthe femoral head component within the acetabular component leadsto polyethylene wear (1–4,20,23,24). Small particle diseasecan take place with any joint arthroplasty.

Femoral stem fracture was seen more commonly in the past whenalloys with relatively low fatigue strength (stainless steel)were used for prosthesis manufacturing. Prosthesis breakagehas become rare with the introduction of high-strength metalalloys (forged cobalt-chromium alloy, titanium-6–aluminum-4–vanadium,and high-strength stainless steel) (20). Dislocation is a relativelyuncommon complication (0.4%–0.8% of cases) in primarytotal hip arthroplasty; it is more common in revision hip arthroplasty(up to 16% of cases) (23).

In the patients with aseptic loosening of the acetabular componentand significant bone loss, several types of reconstruction ringsare available for management of the acetabular bone loss duringrevision hip surgery (Fig 19) (25). Custom endoprostheses areused as needed for limb salvage surgery and occasionally afterfailed primary joint replacement and chronic fracture nonunion(Fig 20) (7).

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Figure 19. Anteroposterior radiograph of the left hip shows an acetabular reconstruction ring placed during total hip revision arthroplasty (Smith & Nephew). Note postoperative overlying drain.

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Figure 20. Anteroposterior radiograph of the left hip shows a custom tumor prosthesis (saddle) (Waldemar link; Hamburg, Germany) in a patient with extensive multiple myeloma lesions involving the left acetabulum and other pelvic bones.

No Benefit to Routine Imaging for Low Back Pain Without "Red Flags"

2009-02-07T02:54:00.001-08:00

Sent to you by Hemi via Google Reader:

No Benefit to Routine Imaging for Low Back Pain Without "Red Flags"

via Medscape Radiology Headlines on 2/6/09

A new meta-analysis of randomized trials finds no benefit to routine lumbar imaging for low back pain on clinical outcomes without so-called "red flags," or indications of serious underlying conditions.
Medscape Medical News

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Subacromial Ultrasound Guided or Systemic Steroid Injection for Rotator Cuff...

2009-02-07T02:49:00.001-08:00

Sent to you by Hemi via Google Reader:

Subacromial Ultrasound Guided or Systemic Steroid Injection for Rotator Cuff Disease: Randomised Double Blind Study

via Medscape Radiology Headlines on 2/6/09

Were there short term differences in outcomes between local ultrasound guided corticosteroid injection and systemic corticosteroid injection in rotator cuff disease?
British Medical Journal

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"Samurai Radiologist" Exposes the Mysterious World of Imaging

2009-02-03T16:36:00.001-08:00

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"Samurai Radiologist" Exposes the Mysterious World of Imaging

via Medscape Radiology Headlines on 2/3/09

With a quirky sense of humor, an experienced radiologist discusses the past and the future of his specialty.
Medscape Med Students

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Superficial Soft-Tissue Masses

2009-02-03T14:54:00.001-08:00

Superficial Soft-Tissue
Masses: Analysis, Diagnosis,
and Differential
Considerations1
Francesca D. Beaman, MD2 ● Mark J. Kransdorf, MD ● Tricia R.
Andrews, MD ● Mark D. Murphey, MD ● Lynn K. Arcara, MD ● James
H. Keeling, MD
A wide variety of superficial soft-tissue masses may be seen in clinical
practice, but a systematic approach can help achieve a definitive diagnosis
or limit a differential diagnosis. Superficial soft-tissue masses can
generally be categorized as mesenchymal tumors, skin appendage lesions,
metastatic tumors, other tumors and tumorlike lesions, or inflammatory
lesions. With regard to their imaging features, these masses
may be further divided into lesions that arise in association with the
epidermis or dermis (cutaneous lesions), lesions that arise within the
substance of the subcutaneous adipose tissue, or lesions that arise in
intimate association with the fascia overlying the muscle. The differential
diagnosis may be limited further by considering the age of the patient,
anatomic location of the lesion, salient imaging features, and
clinical manifestations.
Introduction
Superficial soft-tissue masses are common in clinical practice, and the expanding
availability of radiologic imaging has increased radiologists’ familiarity with these entities.
In the case of some masses, such as superficial lipomas, the imaging characteristics
usually enable a definitive diagnosis. However, the imaging features of many
other superficial soft-tissue lesions may be disappointingly nonspecific, and the possible
diagnostic considerations initially may seem extensive. In such cases, the use of
a systematic approach can help narrow the differential diagnosis.
Superficial soft-tissue masses may be classified in one of the following general diagnostic
categories: mesenchymal tumors, skin appendage lesions, metastatic tumors,
Abbreviation: SE _ spin echo
RadioGraphics 2007; 27:509–523 ● Published online 10.1148/rg.272065082 ● Content Codes:
1From the Departments of Radiology (F.D.B., M.J.K.) and Dermatology (T.R.A., J.H.K.), Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL
32224-3899; and Department of Radiologic Pathology, Armed Forces Institute of Pathology, Walter Reed Army Medical Center, Washington, DC
(M.J.K., M.D.M., L.K.A.). Recipient of a Certificate of Merit award for an education exhibit at the 2005 RSNA Annual Meeting. Received April 26,
2006; revision requested June 12 and received July 26; accepted July 31. All authors have no financial relationships to disclose. Address correspondence
to M.J.K. (e-mail: kransdorf.mark@mayo.edu).
2Current address: Department of Radiology, Washington Hospital Center, Washington, DC.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official nor as reflecting the views of the
Department of the Army or the Department of Defense.
See last page
TEACHING
POINTS
other tumors and tumorlike lesions, and inflammatory
lesions. Although these categories comprise
a plethora of possible diagnoses, an orderly
list of differential considerations may be constructed
by considering the patient’s age, the anatomic
site of the mass, and the specific location of
the mass within the superficial tissue.
For purposes of analysis, it is most useful to
consider two patient age groups: (a) adults and
(b) children and adolescents. The dividing line
between these groups is not rigidly defined, but
we have arbitrarily designated those in the first 2
decades of life as children and adolescents. Anatomic
location is also best considered in general
categories such as the extremity, trunk, or head
and neck. However, certain lesions show a striking
predilection for a more specific anatomic location,
as is true of epithelioid sarcoma, which usually
occurs in the hand and wrist. Epithelioid sarcoma
is rare, accounting for just over 1% of all
sarcomas, but more than 40% of epithelioid sarcomas
occur in the hand and wrist. Finally, the
location of a lesion within the superficial tissue is
best described as cutaneous (epidermis and dermis);
subcutaneous (eg, adipose tissue); or fascial,
overlying the muscle or deep tissue (Fig 1). After
a differential diagnosis is established on the basis
of the patient’s age and the location of the lesion
(anatomic site and specific location within the
superficial tissue), it may be further limited and
ordered, or a specific diagnosis may be made, by
considering that information in combination with
the imaging characteristics.
The article is based on our experience with
superficial soft-tissue masses. It is not intended as
a comprehensive review but, rather, as an overview,
with emphases on lesions that are more
common or relatively more common and on diagnoses
that may be suggested by MR imaging features.
Mesenchymal Tumors
The category of mesenchymal tumors is described
in Table 1. The most common mesenchymal superficial
malignancy is dermatofibrosarcoma protuberans,
which arises from the dermis and therefore
is considered a cutaneous lesion. Dermatofibrosarcoma
protuberans accounts for about 6%
of all soft-tissue sarcomas. The lesions usually
are manifested at MR imaging as unmineralized
nodular masses with nonspecific signal intensity
and moderate enhancement (Fig 2) (1). Other
benign and malignant mesenchymal tumors may
arise in association with the cutaneous tissue, but
Figure 1. Diagram shows the superficial soft-tissue layers.
510 March-April 2007 RG f Volume 27 ● Number 2
Figure 2. Exophytic dermatofibrosarcoma protuberans in the lower thigh of a 45-year-old man.
(a) Axial unenhanced CT image shows a large mass with ulceration at the skin surface (arrowheads).
(b) Axial short inversion time inversion recovery (4000/20/150) MR image shows extension
of the protuberant mass along the skin layers and into the cutaneous and subcutaneous fat.
(c) Photograph of a gross specimen cross section shows the mass with linear extension along the
skin layers (arrows), features identical to those seen at imaging. Scale is in centimeters.
Table 1
Mesenchymal Tumors
Diagnosis Classification Patient Age Comments
Dermatofibrosarcoma
protuberans
Cutaneous Adults (peak,
20–40 years)
Protuberant mass with skin involvement; a fascial
tail may be seen at imaging
Lipoma Subcutaneous Adults Signal intensity mirrors that of fat
Angiomas (hemangioma,
lymphangioma,
mixed)
Subcutaneous All ages Signal intensity is intermediate to high on images
obtained with fluid-sensitive MR pulse sequences
Peripheral nerve sheath
tumor (schwannoma,
neurofibroma)
Cutaneous,
subcutaneous
Adults Neurofibroma is usually associated with NF1;
malignant peripheral nerve sheath tumor is
rare
Malignant fibrous histiocytoma
Subcutaneous Adults Most common soft-tissue sarcoma, usually deep;
7%–10% of lesions are subcutaneous
Liposarcoma Cutaneous
(rare), subcutaneous
Adults Extremities, retroperitoneum; most lesions contain
some amount of fat
Leiomyosarcoma Subcutaneous Adults Nonspecific vascular mass; may be associated
with superficial veins
Epithelioid sarcoma Subcutaneous Adults (peak,
20–40 years)
Occurs on fingers, hands, forearms; imaging features
are nonspecific
Nodular fasciitis Fascial Adults (peak,
20–40 years)
Fascial tail may be seen at imaging
Fibromatosis Fascial Adults Signal intensity is low to intermediate
RG f Volume 27 ● Number 2 Beaman et al 511
their occurrence is unusual. Although the MR
imaging signal intensity of dermatofibrosarcoma
protuberans typically is nonspecific, areas of hemorrhage
may be seen within the tumor. In our experience,
linear extension along the skin surface
also may be seen and is suggestive of the diagnosis
(Fig 2b).
Most mesenchymal masses arise within the
subcutaneous adipose tissue. Lipomas are by far
the most frequently encountered subcutaneous
masses. Eighty percent of lipomas occur in adults,
and they are easily diagnosed on the basis of MR
imaging findings, including a signal intensity that
is characteristic of fat on MR images acquired
with any pulse sequence, as well as a lack of enhancement
after the administration of intravenous
contrast material (Fig 3).
Angiomatous lesions also are common. Hemangiomas
are the most common type of angiomatous
lesions, but mixed hemangiolymphangiomas
and pure lymphangiomas also may be seen. These
lesions produce a wide spectrum of clinical manifestations
and may occur in patients of all ages.
Classic large-vessel (cavernous) hemangiomas
have the generally characteristic imaging appearance
of infiltrative lesions in which serpentine vessels
interdigitate with fibroadipose tissue. Smallvessel
hemangiomas may have a more nonspecific
appearance, and the diagnosis may be suggested
more by their clinical manifestations (Fig 4).
Peripheral nerve sheath tumors are another
common type of mesenchymal tumor. Typically,
an entering and exiting nerve cannot be identified
in superficial lesions; however, the typical fusiform
shape, signal intensity, and enhancement
pattern often are present. Classic peripheral nerve
sheath tumors have a signal that is isointense to
that of skeletal muscle on T1-weighted MR images
and hyperintense to that of skeletal muscle
on T2-weighted images, with variable degrees of
inhomogeneity and enhancement (Fig 5) (2).
The most common subcutaneous malignant
soft-tissue tumor is the superficial variant of malignant
fibrous histiocytoma. Malignant fibrous
histiocytoma is the most common mesenchymal
malignancy and accounts for approximately 24%
of all soft-tissue sarcomas (3), with about 7%–
10% of occurrences being confined to the subcutis,
and there is typically no fascial involvement
(4,5). The superficial form of malignant fibrous
histiocytoma is histologically identical to the pleomorphic
form; however, as a result of its superficial
location, it has a benign clinical course.
Therefore, to distinguish it more clearly from the
deep, more biologically aggressive forms, superficial
malignant fibrous histiocytoma has been
termed atypical fibroxanthoma (6). Hemorrhage
is not uncommon in such lesions and is usually
well depicted on MR images.
Other superficial sarcomatous lesions include
liposarcoma, leiomyosarcoma, and epithelioid
sarcoma. Liposarcoma is the second most common
soft-tissue sarcoma, accounting for 16%–
18% of all malignant soft-tissue tumors. The lesions
usually are located in the extremities, particularly
the thigh, and in the retroperitoneum in
adults 40–59 years old. Superficial liposarcoma is
relatively uncommon, but when a superficial fatty
lesion does not meet the imaging criteria for the
diagnosis of lipoma, a lipoma variant should be
considered as a diagnostic possibility, as should
liposarcoma. The appearance of liposarcoma at
CT and MR imaging typically correlates with the
degree of tumor differentiation; tumors that are
more differentiated contain more fat and less soft
tissue (3).
Leiomyosarcoma accounts for about 5%–10%
of soft-tissue sarcomas (6). The lesions are highly
vascular, occur most often in mature adults, and
have a propensity to recur and metastasize. They
are often intimately associated with vessels. At
ultrasonography (US), they appear as circumscribed
echogenic masses, with marked internal
vascularity seen on Doppler US images. MR imaging
features usually are not specific (Fig 6).
Figure 3. Superficial (subcutaneous) lipoma
in a 51-year-old man with a large posterior
neck mass. Sagittal T1-weighted (620/17)
spin-echo (SE) MR image shows a well-marginated
lipomatous mass (*) in the subcutaneous
fat. The signal intensity of the lesion on all
MR images was identical to that of fat.
512 March-April 2007 RG f Volume 27 ● Number 2
Teaching
Point
Figure 4. Juvenile capillary hemangioma (strawberry nevus) in a 2-month-old girl.
(a) Axial unenhanced CT image shows infiltration of the skin and orbit (arrow). (b) Axial
T2-weighted (2000/80) SE MR image depicts a mass (*) that has infiltrated the subcutaneous
and deeper soft tissues. The signal intensity of the lesion at T2-weighted imaging was
nonspecific.
Figure 5. Multifocal
cutaneous neurofibromas
in a 78-
year-old man with
type 1 neurofibromatosis.
(a) Axial CT
image of the abdomen,
obtained with
oral and intravenous
contrast material,
shows multifocal
isoattenuating softtissue
masses (arrowheads)
indicative
of neurofibromas.
(b, c) Sagittal T2-
weighted turbo SE
(4000/102) MR image
(b) and sagittal
gadolinium-enhanced
fat-suppressed
T1-weighted
SE (650/16) MR image
(c) show hyperintense
signal in the
enhanced cutaneous
masses (arrows).
RG f Volume 27 ● Number 2 Beaman et al 513
Figure 6. Leiomyosarcoma arising from the
saphenous vein in a 53-year-old man. (a) Doppler
US image shows a circumscribed echogenic
mass with marked hypervascularity.
(b, c) Axial T1-weighted (802/17) (a) and
axial T2-weighted (2350/80) (b) SE MR images
show a circumscribed soft-tissue mass
(arrow) in the subcutaneous adipose tissue.
The signal intensity of the mass is indicative
of a solid lesion. (d) Axial gadolinium-enhanced
T1-weighted (675/17) fat-suppressed
SE MR image shows homogeneous moderate
enhancement of the mass (arrow). (e) Photograph
of the gross specimen shows a lobulated
mass that surrounds the saphenous vein (arrow).
Scale is in centimeters.
514 March-April 2007 RG f Volume 27 ● Number 2
Epithelioid sarcoma, conversely, is a rare sarcoma
that is seen predominantly in male adolescents
and young adults (ages 10–35 years). It is
manifested as a firm, solid single nodule or multiple
nodules that most commonly are located on
the forearms, hands, or fingers (6). Although epithelioid
sarcoma comprises only approximately
1%–2% of all soft-tissue sarcomas, it represents
21%–29% of all malignant lesions of the hand
and wrist in patients between the ages of 16 and
35 years. At radiography, epithelioid sarcoma
may appear as a soft-tissue mass with occasional
speckled calcification, cortical thinning, and osseous
erosion (6).
It is especially noteworthy that a superficial
lesion that extends through the fascia is more
likely to be a malignancy (Fig 7) (7).
Nodular fasciitis and fibromatosis are two entities
that may arise in the fascial layer. Nodular
fasciitis is a pseudosarcomatous benign fibrous
tumor that is thought to be reactive in etiology
and, therefore, to be self-limiting. It is primarily
located in the upper extremities in young adults
(ages 20–40 years) (6). At MR imaging, nodular
fasciitis demonstrates a nonspecific signal intensity.
After the administration of contrast material,
there is usually diffuse enhancement. An important
diagnostic feature at MR imaging is the linear
extension of the lesion along the fascia (fascial tail
sign), which also may appear enhanced (Fig 8).
Fibromatosis is a locally aggressive benign tumor
Figure 7. Superficial malignant fibrous histiocytoma in the upper thigh of a 78-year-old man. (a) Coronal
T1-weighted (700/13) SE MR image shows a large hypointense mass (arrows) that has arisen in the
subcutaneous tissue and has invaded and penetrated the tensor fascia lata. (b) Axial T2-weighted (2540/
80) SE MR image shows heterogeneously hypointense signal in the mass, as well as abnormal thickening
of the tensor fascia lata (arrow).
Figure 8. Nodular
fasciitis in the upper arm
of a 16-year-old boy.
Coronal T1-weighted
(600/20) (a) and coronal
T2-weighted (2000/
80) (b) SE MR images
of the shoulder show a
well-defined mass superficial
to the deltoid
muscle with a small linear
area of extension in
the proximal fascia (arrow
in b).
RG f Volume 27 ● Number 2 Beaman et al 515
Teaching
Point
that typically is seen in adults and that has low to
intermediate signal intensity on MR images
(Fig 9).
Skin Appendage Lesions
Skin appendage lesions originate in the epidermis
and dermis (Table 2). They are typically subcategorized
as proliferations of follicular lineage or
eccrine-apocrine differentiation. The lesions are
typically small and, consequently, are diagnosed
clinically. Imaging features are not usually specific,
and imaging is reserved for unusually large
or atypical lesions; however, such lesions often are
incidental findings at imaging.
The most common of these is probably the
infundibular cyst, or epidermal cyst. This simple
epithelial cyst is lined with infundibular or epidermal-
like cells that keratinize (8). The term sebaceous
cyst is a misnomer and should be avoided,
because these cysts are not of sebaceous differentiation
and their imaging characteristics vary according
to their internal contents. Large lesions
may contain dependent debris. Most frequently,
lesions are small and unilocular; however, large
multiloculated lesions may be manifested with a
rim of peripheral enhancement (9). At US, the
cyst appears as a circumscribed circular or oval
hypoechoic mass, often in association with a hair
follicle. The lesion has attenuation that is similar
to that of skeletal muscle on CT images and MR
signal that is isointense or slightly hypointense
compared with the signal in skeletal muscle on
T1-weighted MR images and hyperintense compared
with that on T2-weighted MR images (Fig
Figure 9. Musculoskeletal fibromatosis in the paraspinal region in a 20-year-old man. (a) Axial T1-weighted (800/
20) SE MR image shows markedly decreased signal intensity within a well-defined mass (arrows), a finding indicative
of a densely collagenous hypocellular lesion. The mass extends across the midline (arrowheads). T2-weighted images
(not shown) also showed decreased signal intensity in the mass. (b) Corresponding contrast-enhanced CT image
shows enhancement of the lesion and small fascial “tails” (arrowheads).
Table 2
Skin Appendage Lesions
Diagnosis Classification Patient Age Comments
Epidermal inclusion
cyst
Cutaneous (dermal) Adults Most common dermal cyst, often an
incidental finding at imaging
Pilomatricoma Cutaneous (dermal) Bimodal: children and
adults
Benign calcifying tumor
Cystadenoma Cutaneous (dermal) Adults Cystic ectasia of the dermal portion
of the eccrine duct
Cylindroma Cutaneous (dermal) Adults, mostly women Occurs on head, neck, and scalp
Syringoma Cutaneous (dermal) Adults Occurs on eyelids and upper cheeks
516 March-April 2007 RG f Volume 27 ● Number 2
Teaching
Point
10). No appreciable enhancement of the lesion
should be seen.
Pilomatricoma is a benign calcifying tumor
that is thought to arise from skin appendages
(10). The lesion arises in the dermis from primitive
cells that normally differentiate into hair matrix
cells (11,12). Although pilomatricoma accounts
for less than 1% of skin tumors, it is the
most common solid cutaneous tumor in patients
20 years of age and younger (13), with a secondary
peak occurrence among mature adults (ages
50–65 years). Tumors are small (usually less than
3 cm in diameter), grow slowly, are confined to
the subcutaneous tissue (10,11), and are seen
most commonly on the face, neck, and arms. Calcification,
which is more typically central, is seen
in about 85% of lesions (Fig 11).
Large lesions that arise in association with eccrine
(sweat) glands also may be manifested as
soft-tissue masses. Eccrine cystadenoma (eccrine
hidrocystoma) arises because of cystic ectasia of
the dermal portion of the eccrine duct, which results
in retention of secretions within simple cysts.
A large lesion of this type may be manifested as a
lobulated cystic mass. Contrast-enhanced MR
imaging has been reported to show enhancement
of the cyst wall with occasional small enhancing
papillary areas that projected into the lumen (14).
Cylindroma and syringoma are dermal tumors
of apocrine differentiation. They are characterized
by their clinical appearance and are not likely
to be encountered by a musculoskeletal specialist.
Cylindromas are seen primarily on the head,
neck, and scalp in women (Fig 12). Syringomas
are also predominantly found on the head in
adults, specifically on the eyelids and upper
cheeks.
Figure 10. Infundibular cysts at MR imaging and US. (a, b) Axial T1-weighted (600/20) (a)
and axial T2-weighted (2500/80) (b) SE MR images of the knee of a 45-year-old man with a history
of a mass for approximately 30 years show a well-defined but nonspecific mass (*) in the subcutaneous
adipose tissue. The lesion contents appear heterogeneous on the T2-weighted image,
with debris in the dependent aspect. (c) US image in a different patient shows an infundibular cyst
located in the skin (arrow) and two hairs (arrowheads) emerging from the cyst.
Figure 11. Pilomatricoma in the neck of a 7-year-old
boy. Axial contrast-enhanced CT image obtained with
bone window settings shows a mineralized mass (arrow)
with delicate ossification that is more prominent
peripherally.
RG f Volume 27 ● Number 2 Beaman et al 517
Metastatic Tumors
Soft tissue is relatively resistant to metastasis; although
soft tissue accounts for about 40% of total
body weight, soft-tissue metastases are very rare.
However, any malignancy may disseminate to the
skin, and 5%–10% of all cancer patients develop
skin metastases (Table 3). At clinical examination,
numerous small, hard or rubbery nodules
are found, typically on the chest, abdomen, or
scalp of an adult older than 40 years. Skin involvement
typically occurs near the site of the primary
tumor. Because of overall disease prevalence,
breast cancer is the most common primary
lesion that metastasizes to the skin in women
(15). In men, skin metastases from malignant
melanoma are most common, followed by those
from lung cancer (15). Cutaneous metastases are
frequently identified in clinical practice, but they
are uncommonly subjected to radiologic imaging.
Metastatic melanoma may be manifested with
a similar pattern of multiple subcutaneous nodu-
Figure 12. Multiple facial cylindromas in a 79-year-old woman. (a) Clinical photograph
of the patient’s ear shows numerous soft-tissue masses. (b) Axial unenhanced CT image
shows multiple isoattenuating cutaneous masses that involve both ears.
Table 3
Metastatic Tumors
Diagnosis Classification Patient Age Comments
Carcinoma Cutaneous Adults 5%–10% of all cancers; most common on the
chest, abdomen, and scalp
Melanoma Subcutaneous Adults Seen in 30% of patients with metastatic melanoma;
internal hemorrhage not uncommon
Myeloma Cutaneous, subcutaneous Adults Soft tissue is a frequent site of extraosseous
involvement
Table 4
Other Tumors and Tumorlike Lesions
Diagnosis Classification Patient Age Comments
Myxoma Cutaneous, subcutaneous Adults Characterized by fluidlike signal intensity,
variable enhancement
Lymphoma Cutaneous, subcutaneous Adults Primary soft-tissue lymphoma is rare
Granuloma
annulare
Cutaneous, subcutaneous Adults (cutaneous);
children, adolescents
(subcutaneous)
Subcutaneous form may be manifested
as a soft-tissue mass; decreased signal
intensity at MR imaging
518 March-April 2007 RG f Volume 27 ● Number 2
lar lesions, and its presence must be considered in
a patient who presents with multiple subcutaneous
nodules (16).
Teaching
Point
Such nodules are seen in more
than 30% of patients with metastatic melanoma,
usually in those with Clark level IV or V disease
(tumor invasion of the deep dermis or subcutaneous
fat), and they may be the only radiologic
manifestation of metastatic disease (Fig 13) (16).
Extraosseous manifestations of multiple myeloma
are found in less than 5% of patients and
are associated with more aggressive disease (17).
In patients with extraosseous disease, the typical
manifestation is a cutaneous or subcutaneous
nodule or nodules (17).
Other Tumors
and Tumorlike Lesions
Myxoma is a benign lesion characterized by an
abundant myxoid matrix and a paucity of spindleshaped
stromal cells. Perceived as rare, these lesions
are more common in surgical series and represent
approximately 3% of all benign tumors
subjected to biopsy. According to a report from
the Armed Forces Institute of Pathology about
approximately 200 myxomas of various anatomic
sites, 15% of the lesions arose in the cutaneous
tissue and 22% in the subcutaneous and aponeurotic
tissues (3,18,19). Myxoma typically shows a
homogeneous fluidlike signal intensity (Fig 14,
Table 4). At contrast-enhanced imaging, lesions
show variable enhancement. Occasionally, extensive
heterogeneous enhancement is seen.
Figure 13. Subcutaneous metastatic melanoma in a 68-year-old woman. (a, b) Sagittal
T1-weighted (406/17) (a) and axial gadolinium-enhanced T1-weighted (433/17) fat-suppressed
(b) SE MR images show a well-defined subcutaneous solid mass (arrow) in the posterior
aspect of the right thigh. Intense homogeneous enhancement of the mass is seen in b.
(c) Axial positron emission tomographic image of the thighs shows two hypermetabolic foci
(arrowheads) that correspond to melanoma metastases. The lesion in the right thigh correlates
with that in a and b.
Figure 14. Subcutaneous myxoma in the lower
leg of a 32-year-old man. Axial T2-weighted
(2500/90) SE MR image shows a well-defined
subcutaneous mass (*) anterior to the tibia. The
large size of the lesion makes it difficult to determine
whether its origin is in subcutaneous tissue
or the aponeurosis.
RG f Volume 27 ● Number 2 Beaman et al 519
Cutaneous lymphomas may be broadly classified
as primary (with no evidence of extracutaneous
involvement) or secondary (with evidence of
simultaneous or previous extracutaneous involvement).
They may be further subclassified according
to cell type: B cell, T cell, histiocytic, and
other (rare) (15). Primary lymphoma of soft tissue
is exceedingly rare, and patients often present
with a palpable mass that simulates a soft-tissue
sarcoma. At imaging, associated abnormalities in
adjacent osseous structures or lymph nodes often
are identified, and such findings allow the inclusion
of lymphoma in the differential diagnosis.
When lymphoma is manifested as an isolated softtissue
or subcutaneous mass, the imaging features
are nonspecific (Fig 15) (3).
Granuloma annulare is a benign inflammatory
dermatosis, with a common cutaneous form
found in adults and an uncommon subcutaneous
form found in children and adolescents. The cutaneous
form is diagnosed clinically and therefore
is rarely encountered by the radiologist, whereas
the subcutaneous form may be manifested as a
superficial mass. Radiographs show a circumscribed
nodular mass that is localized to the subcutaneous
tissues, with an absence of both bone
involvement and mineralization. The mass shows
decreased signal intensity at MR imaging and
variable enhancement after the administration of
contrast material (Fig 16).
Figure 15. Superficial B cell lymphoma in the forearm of a 53-year-old man. Axial T1-weighted
(716/9) (a) and axial T2-weighted (2350/80) fat-suppressed (b) SE MR images show a large homogeneous
mass (*) with nonspecific features in the cutaneous and subcutaneous compartments.
The mass demonstrated signal intensity slightly higher than that in skeletal muscle at T1-weighted
imaging, high signal intensity at T2-weighted imaging, and intense homogeneous enhancement at
gadolinium-enhanced MR imaging.
Table 5
Inflammatory Lesions
Diagnosis Classification Patient Age Comments
Cellulitis Cutaneous,
subcutaneous
All ages Skin thickening with reticulated fluidlike signal intensity in
the subcutaneous tissues
Fasciitis Fascial All ages Fascial thickening and enhancement
Adenitis Subcutaneous Children,
adolescents
Signal intensity is typically intermediate on T2-weighted,
non–fat-suppressed images
Abscess Subcutaneous All ages Fluidlike signal intensity, rim of enhancement
520 March-April 2007 RG f Volume 27 ● Number 2
Inflammatory Lesions
In general, the term cellulitis is used to describe an
inflammation or infection of the cutaneous and
subcutaneous tissues, without gross suppuration
(Table 5). Fasciitis is inflammation or infection of
the fascia, and adenitis is inflammation or infection
of one or more lymph nodes. Cat-scratch
disease is a common and benign form of regional
lymphadenitis that is associated with exposure to
cats. The condition is caused by infection with
Bartonella henselae, a Gram-negative bacillus.
Most of those affected are young; two-thirds of
cases occur in patients between the ages of 5
and 21 years (20). MR imaging shows regional
lymphadenopathy with surrounding edema (Fig
17) (20). Involvement of a single node is seen in
Figure 16. Granuloma annulare
in the lower leg of a
5-year-old girl. Axial T1-
weighted (500/20) (a) and
axial T2-weighted (2000/
80) (b) SE MR images show a
mass in the subcutaneous tissue
of the anterior part of the
leg (arrow). The lesion had
decreased signal intensity and
a somewhat indistinct margin
on all MR images.
Figure 17. Cat-scratch disease in a 26-year-old man with a rapidly growing, painful mass in the groin. (a) Coronal
T2-weighted (5950/68) SE MR image shows a nodal mass (arrow) in the right side of the groin, with prominent associated
edema (arrowhead). (b) Axial T1-weighted (600/15) SE MR image shows a large right inguinal node with surrounding
edema (arrow). On MR images obtained after contrast material was administered, the node demonstrated
mild heterogeneous enhancement. The findings were indicative of lymphadenopathy.
RG f Volume 27 ● Number 2 Beaman et al 521
44%–85% of patients. At MR imaging or CT,
fasciitis is characterized by fascial enhancement,
which may have various causes. Necrotizing fasciitis
is diagnosed in the presence of one or more
regions of nonenhanced fascia, a finding indicative
of nonvascularized tissue, within an otherwise
markedly enhanced fascial layer (Fig 18).
An abscess, in contradistinction, is defined as a
focal collection of pus (or necrotic tissue, white
blood cells, and bacteria) that is confined to a
specific space, tissue, or organ (21,22). An abscess
may, with time, become walled off by highly
vascularized connective tissue (23) and may be
associated with diffuse inflammation.
At MR imaging, the appearance of a soft-tissue
abscess varies with the virulence of the organism
and the host’s reaction to the organism. In general,
areas of suppuration demonstrate signal
intensity similar to that of fluid, and the internal
contents of the lesion appear relatively homogeneous.
However, the degree of homogeneity
and the signal intensity vary, depending on the
amount of internal proteinaceous debris, necrosis,
foreign matter, and gas (24). MR images depict
a lesion with a peripheral rim of variable signal
intensity that is markedly enhanced after the administration
of intravenous gadolinium (24). A
Figure 18. Necrotizing fasciitis in a 51-year-old diabetic man with rapidly progressing pain and
swelling in the thigh. (a, b) Axial T1-weighted (716/15) (a) and axial fat-suppressed T2-weighted
(6566/105) (b) SE MR images show a reticulated pattern of abnormal signal intensity within the subcutaneous
tissues, a pattern suggestive of cellulitis; an extensive region of abnormal signal intensity (*) centered
on the fascia, a finding indicative of fasciitis; and areas of abnormal signal intensity in the adjacent
muscle (arrows in b), features indicative of associated myositis. (c) Axial T1-weighted (650/15) SE MR
image obtained after the administration of intravenous gadolinium shows nonenhanced fascial tissue laterally
(*) and anteriorly. Necrosis of the fascia (necrotizing fasciitis) was identified at surgery.
522 March-April 2007 RG f Volume 27 ● Number 2
Teaching
Point
discrete abscess may be differentiated from a diffuse
inflammatory process (phlegmon) in that the
latter appears as a poorly defined region with increased
signal intensity on T2-weighted images
and with an indistinct margin (an edema-like pattern),
but without the internal high signal intensity
typically seen in a focal fluid collection.
Conclusions
Soft-tissue malignancies are relatively uncommon,
in comparison with the large number of benign
lesions that may be seen in the superficial
tissue. The imaging appearance of a superficial
mass often yields limited information to help narrow
the differential diagnosis. Therefore, not only
the imaging appearance but also the lesion location
and the patient’s age should be considered
when evaluating a superficial mass.
References
1. Kransdorf MJ, Meis-Kindblom JM. Dermatofibrosarcoma
protuberans: radiologic appearance.
AJR Am J Roentgenol 1994;163:391–394.
2. Beaman FD, Kransdorf MJ, Menke DM. Schwannoma:
radiologic-pathologic correlation. Radio-
Graphics 2004;24:1477–1481.
3. Kransdorf MJ, Murphey MD. Imaging of soft tissue
tumors. 2nd ed. Philadelphia, Pa: Lippincott
Williams & Wilkins, 2006; 6–37, 80–149.
4. Weiss SW, Enzinger FM. Malignant fibrous histiocytoma:
an analysis of 200 cases. Cancer 1978;41:
2250–2266.
5. Guillen DR, Cockerel CJ. Cutaneous and subcutaneous
sarcomas. Clin Dermatol 2001;19:262–
268.
6. Weiss SW, Goldblum JR. Enzinger and Weiss’s
soft tissue tumors. 4th ed. St. Louis, Mo: Mosby,
2001; 535–569, 1483–1571.
7. Galant J, Marti-Bonmati L, Soler R, et al. Grading
of subcutaneous soft tissue tumors by means of
their relationship with the superficial fascia on MR
imaging. Skeletal Radiol 1998;27:657–663.
8. Murphy GF, Elder DE. Atlas of tumor pathology:
non-melanocytic tumors of the skin. Washington,
DC: Armed Forces Institute of Pathology, 1991;
61–153.
9. Fisher AR, Mason PH, Wegenhals KS. Ruptured
plantar epidermal inclusion cyst. AJR Am J Roentgenol
1998;171:1709–1710.
10. Wickremaratchi T, Collins CM. Pilomatrixoma or
calcifying epithelioma of Malherbe invading bone.
Histopathology 1992;21:79–81.
11. Haller JO, Kassner EG, Ostrowitz A, Kottmeler
K, Perfschuk LP. Pilomatrixoma (calcifying epithelioma
of Malherbe): radiographic features.
Radiology 1977;123:151–153.
12. Forbis R, Helwig EB. Pilomatrixoma (calcifying
epithelioma). Arch Dermatol 1961;83:606–618.
13. Marrogi AJ, Wick MR, Dehner LP. Pilomatrical
neoplasms in children and young adults. Am J
Dermatopathol 1992;14:87–94.
14. Quek ST, Tyrrell PN, Darby AJ. MRI of eccrine
cystadenoma. J Comput Assist Tomogr 2000;24:
293–295.
15. James WD, Berger TG, Elston DM. Andrews’
diseases of the skin: clinical dermatology. Philadelphia,
Pa: Saunders, 2006; 628–630.
16. Patten RM, Shuman WP, Teefey S. Subcutaneous
metastases from malignant melanoma: prevalence
and findings on CT. AJR Am J Roentgenol 1989;
152:1009–1012.
17. Moulopoulos LA, Granfield CA, Dimopoulos
MA, Kim EE, Alexanian R, Libshitz HI. Extraosseous
multiple myeloma: imaging features.
AJR Am J Roentgenol 1993;161:1083–1087.
18. Enzinger FM. Intramuscular myxoma: a review
and follow-up study of 34 cases. Am J Clin Pathol
1965;43:104–113.
19. Steinbach LS, Johnston JO, Tepper EF, Honda
GD, Martel W. Tumoral calcinosis: radiologicpathologic
correlation. Skeletal Radiol 1995;24:
573–578.
20. Hopkins KL, Simoneaux SF, Patrick LE, Wyly JB,
Dalton MJ, Snitzer JA. Imaging manifestations of
cat-scratch disease. AJR Am J Roentgenol 1996;
166:435–438.
21. Robbins SL. Pathology of disease. Philadelphia,
Pa: Saunders, 1974; 55–105.
22. Beauchamp NJ, Scott WW, Gotttlieb LM, Fishman
EK. CT evaluation of soft tissue and muscle
infection and inflammation: a systemic compartmental
approach. Skeletal Radiol 1995;24:317–
324.
23. Hajdu SI. Soft tissue sarcomas: classification and
natural history. CA Cancer J Clin 1981;31:271–
280.
24. Hopkins KL, Li KC, Bergman G. Gadolinium-
DTPA-enhanced magnetic resonance imaging of
musculoskeletal infectious processes. Skeletal Radiol
1995;24:325–330.
RG f Volume 27 ● Number 2 Beaman et al 523
RG Volume 27 Volume 2 March-April 2007 Beaman et al
Superficial Soft-Tissue Masses: Analysis, Diagnosis, and
Differential Considerations
Francesca D. Beaman, MD et al
Page 512
Lipomas are by far the most frequently encountered subcutaneous masses.
Page 515
It is especially noteworthy that a superficial lesion that extends through the fascia is more likely to be
a malignancy.
Page 516
The most common of these [skin appendage lesions] is probably the infundibular cyst, or epidermal
cyst. This simple epithelial cyst is lined with infundibular or epidermal-like cells that keratinize (8).
The term sebaceous cyst is a misnomer and should be avoided, because these cysts are not of
sebaceous differentiation and their imaging characteristics vary according to their internal contents.
Page 518
Metastatic melanoma may be manifested with a similar pattern of multiple subcutaneous nodular
lesions, and its presence must be considered in a patient who presents with multiple subcutaneous
nodules.
Page 522
At MR imaging, the appearance of a soft-tissue abscess varies with the virulence of the organism and
the host’s reaction to the organism.

[Musculoskeletal Imaging] Three-dimensional Isotropic Shoulder MR Arthrograp...

2009-02-02T15:51:00.000-08:00

Sent to you by Thrombolyser via Google Reader:

[Musculoskeletal Imaging] Three-dimensional Isotropic Shoulder MR Arthrography: Comparison with Two-dimensional MR Arthrography for the Diagnosis of Labral Lesions at 3.0 T

via Radiology Musculoskeletal Imaging by Jung, J. Y., Yoon, Y. C., Choi, S.-H., Kwon, J. W., Yoo, J., Choe, B.-K. on 2/2/09

Purpose: To compare the diagnostic accuracy of three-dimensional (3D) isotropic magnetic resonance (MR) arthrography with two-dimensional (2D) MR arthrography for the diagnosis of labral lesions of the shoulder performed by using a 3.0-T imager.

Materials and Methods: Institutional review board approval was given for this retrospective study and informed consent was waived. From March 2006 to January 2007, 100 patients underwent 3D isotropic and 2D MR shoulder arthrographic imaging by using a 3.0-T imager and subsequent arthroscopic surgery. The 3D isotropic sequences were performed by using fast gradient-echo imaging with fat suppression (voxel size, 0.6 x 0.6 x 0.6 mm; imaging time, 5 minutes 32 seconds) and were evaluated for the presence of superior, anterior, and posterior labral lesions by using 3D isotropic and 2D MR arthrography. The statistical differences between the sensitivity and specificity for both methods were analyzed by using the McNemar test, with arthroscopic findings regarded as reference standard.

Results: Surgical findings confirmed 53 superior labral anterior posterior (SLAP) lesions, 17 anterior labral lesions, and five posterior labral lesions. Respective sensitivity and specificity were 85% and 96% for SLAP lesions, 100% and 98% for anterior labral lesions, and 80% and 99% for posterior labral lesions by using 2D MR arthrography and 83% and 96% for SLAP lesions, 100% and 96% for anterior labral lesions, and 80% and 99% for posterior labral lesions by using 3D isotropic MR arthrography. There was no significant difference in sensitivities and specificities of both methods; however, the power of this study was limited and larger comparison is needed.

Conclusion: Isotropic 3D shoulder MR arthrography combined with a multiplanar reconstruction technique can help in the diagnosis of shoulder labral lesions as does 2D MR arthrography, but with shorter imaging times.

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Multiple Sclerosis, Spine: [Print] - eMedicine Radiology - Sent using Google Toolbar

2009-02-02T01:04:00.001-08:00

Multiple Sclerosis, Spine: [Print] - eMedicine Radiology

emedicine.medscape.com

eMedicine Specialties > Radiology > Brain/Spine

Multiple Sclerosis, Spine

Djamil Fertikh, MD, Attending Physician, Division of Radiology, Association of Alexandria Radiologists
Michael L Brooks, MD, JD, FCLM, Clinical Associate Professor of Radiology, Philadelphia College of Osteopathic Medicine; Director of Neuroradiology, Mercy Diagnostic Imaging, Department of Radiology, Mercy Fitzgerald Hospital

Updated: May 24, 2008

Introduction

Background

Multiple sclerosis (MS) is considered the most common demyelinating process involving the central nervous system (CNS).¹ In 1988, MS was first described in the upper cervical spine using magnetic resonance imaging (MRI). Spinal MS is often associated with concomitant brain lesions; however, as many as 20% of patients with spinal lesions do not have intracranial plaques. No strong correlation has been established between the extent of the plaques and the degree of clinical disability.

For excellent patient education resources, visit eMedicine's Muscle Disorders Center. Also, see eMedicine's patient education article Multiple Sclerosis.

Related eMedicine articles:
Brain, Multiple Sclerosis
Multiple Sclerosis [Emergency Medicine]
Multiple Sclerosis [Neurology]
Multiple Sclerosis [Ophthalmology]
Multiple Sclerosis [Physical Medicine and Rehabilitation]

Related Medscape topic:
Resource Center Multiple Sclerosis

Pathophysiology

The exact cause of MS remains unclear; however, hypotheses include viral and autoimmune etiologies.

In the acute stage, perivenular inflammation with hypercellularity (macrophages and/or lymphocytes) is encountered in typically well-demarcated areas of demyelination.

In the chronic stages of the disease, fibrillary gliosis occurs with a breakdown of myelin. The axonal structure is conserved, with a reduction or absence of oligodendroglia. Occasionally, lesions resolve incompletely, but most progress to demyelination.

Frequency

United States

There are an estimated 250,000-350,000 patients in the United States with MS.

International

MS occurs worldwide.² Its prevalence varies depending on the geographic location, rising as the northerly or southerly distance from the equator increases. Depending on the country or the specific population, the prevalence of MS ranges from 2 cases per 100,000 population to 150 cases per 100,000 population.

Related Medscape topic:
CME The Impact and Burden of Multiple Sclerosis

Mortality/Morbidity

The morbidity and mortality rates related to MS are high worldwide.
At 15 years after the onset of the disease, an estimated 50% of patients need help with ambulation.

Related Medscape topics:
CME Evaluating New Data for the Treatment of MS
CME/CE Specialty Pharmacy & Treatment Optimization: Applications for the Multiple Sclerosis Population

Race

Epidemiologic series have shown that western Europeans living in temperate zones have a higher risk for MS than do other groups.

Sex

The male-to-female ratio is 2:3.

Age

MS frequently occurs in persons aged 10-50 years. However, MS has also been described in the pediatric population and in individuals older than 50 years.

Anatomy

Spinal MS has a predilection for the cervical spinal cord (67% of cases), with preferential, eccentric involvement of the dorsal and lateral areas of the spinal cord abutting the subarachnoid space around the cord. The gray matter may be involved. Approximately 55-75% of patients with MS have spinal lesions at some point during the course of the disease.

Presentation

The clinical signs vary depending on the spinal cord segment affected and the degree of involvement. MS is characterized by a typical relapsing-remitting clinical course. Spastic paraparesis/paraplegia with neurogenic bowel and bladder, as well as with sexual dysfunction, can be encountered. Dysesthetic pain syndromes may result from spinal or cranial nerve root involvement.

Heredity is suggested to be involved in the etiology of the disease because affected relatives occasionally are identified.

A concomitant presence of optic neuritis (unilateral, bilateral, or chiasm) constitutes Devic neuromyelitis optica. The brain is usually normal, but the condition is associated with a poor prognosis.

MS can be seen with Leber hereditary optic neuropathy, which is called Harding's syndrome.³

Preferred Examination

Although nonspecific, MRI is presently considered to be the most sensitive diagnostic imaging modality for revealing demyelinating plaques. MRI shows abnormalities in 95% of patients with clinically definitive MS.^{4, 5}

Limitations of Techniques

MRI is sensitive to areas of demyelination, which appear as high signal areas on long TR sequences. Lesions of other etiologies (eg, viral myelitis, acute disseminated encephalomyelitis [ADEM]) may resemble MS plaques and must be considered along with the clinical history and the patient's presenting signs and symptoms.

Differential Diagnoses

Sarcoidosis
Systemic Lupus Erythematosus

Computed Tomography

Findings

With the advancement of MRI, evaluation of the spinal cord using axial computed tomography (CT) scanning was abandoned because of its poor sensitivity. Large, masslike lesions can occasionally mimic a neoplasm, and characterizing them can be difficult.

Degree of Confidence

As a result of CT scanning's poor sensitivity, the detection, evaluation, and characterization of MS lesions and enhancement patterns are limited with this modality.

False Positives/Negatives

Primary and secondary neoplasms of the spinal cord (astrocytomas, ependymomas), infection, transverse myelitis, acute infarction, sarcoidosis, and systemic lupus erythematosus may mimic demyelinating MS plaques.

Magnetic Resonance Imaging

Findings

MRI far exceeds CT scanning in the ability to demonstrate intramedullary pathology; MRI is currently used for the first-line investigation.⁶

Depending on their age, MS plaques appear on unenhanced, T1-weighted images as areas of slightly low to low signal intensity. Plaques may appear as nodules, rings, or arcs and generally are less than 2 vertebral bodies in length.⁷ Plaques usually demonstrate prompt enhancement after the administration of a gadolinium-based contrast agent, which most often indicates active disease.⁸ The enhancement may last 2-8 weeks. Steroids typically do not suppress the enhancement of the active plaques. Classic chronic lesions do not demonstrate contrast enhancement.

Most MS plaques appear hyperintense on T2-weighted images. The spinal cord may or may not be focally enlarged. Enlargement of the cord is usually seen with active disease. Larger active lesions may have extensive edema with associated cord expansion. Chronic lesions often demonstrate focal cord atrophy. Spinal lesions usually coexist with more severe concomitant brain plaques. As many as 20% of spinal MS lesions are isolated. Spinal cord narrowing due to atrophic changes is present in 10% of patients with spinal cord involvement.

Tumefacient MS may mimic a neoplasm; a demyelinating process should always be considered if a masslike lesion is encountered. As is the case in the brain, a ring or arc of enhancement can often be found, as opposed to a more nodular or masslike enhancement. Follow-up studies are helpful.

Although not widely implemented, newer methods may be more specific in evaluating MS plaques.⁹ These methods include magnetization transfer and diffusion, as well as proton magnetic resonance spectroscopy (MRS).^{10, 11}

Typically, fast-FLAIR (fluid-attenuated inversion recovery) sequences have been shown to have a lower sensitivity than do fast spin-echo sequences (FSE) for depicting spinal cord MS lesions.^{12, 13, 14}

Studies have suggested that more cervical cord MS lesions can be revealed with magnetization transfer–prepared gradient-echo and fast-STIR (short TI inversion recovery) sequences than with FSE sequences, with fast-STIR demonstrating the greatest sensitivity.^{13, 15, 16, 17, 18}

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or magnetic resonance angiography (MRA) scans.

As of late December 2006, the Food and Drug Administration (FDA) had received reports of 90 such cases. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

Degree of Confidence

Although MRI is not specific, it is considered the most sensitive imaging modality for diagnosing spinal cord MS, for evaluating its extent, and for following up the response to treatment. MRI is more sensitive for identifying active plaques than is double-dose CT scanning or clinical examination.

False Positives/Negatives

The main differentials include, but are not limited to, the following:

Primary or metastatic spinal cord neoplasms (eg, astrocytomas, ependymomas) - The presence of cysts and hemorrhage support the diagnosis of neoplasm.
ADEM - This may show enhancement. The concomitant presence of brain lesions is the rule. It runs a monophasic course; therefore, it does not have the relapsing course of MS. A history of viral infection within the previous 3-4 weeks should alert the radiologist. ADEM is typically monophasic.
Sarcoidosis - This involves the CNS in approximately 5% of cases. Concomitant pial involvement is frequently encountered. Enhancement is usually the rule.
Transverse myelitis - This term is usually used for idiopathic inflammatory myelopathy. Cord swelling and enhancement may be present, often involving a longer segment than MS. MRI of the brain may be helpful for showing additional lesions in case of MS or ADEM. This condition usually responds to steroid therapy; therefore, a treatment trial is often considered before proceeding with biopsy. This process is typically monophasic.
Infarct - This is more common at the thoracic level. Usually, only a single lesion is present. Contrast may be present, although this is not the dominant feature. Signal alteration usually and initially involves the anterior gray matter (anterior spinal artery distribution). The patient's clinical presentation will be acute. Particularly consider this entity if the patient is older and/or has a history of aortic/vascular surgery.
Vasculitis - Processes such as systemic lupus erythematosus can result in spinal lesions that mimic MS. Often, multiple lesions are present. However, the clinical history is often known and helps to establish the correct diagnosis.
Radiation myelitis - Generally, doses higher than 4000 cGy are required to cause this condition. The latency period is 1-3 years. Chemotherapy may be synergistic. Images may show some peripheral enhancement.
Arteriovenous fistula - Usually, this occurs at the thoracolumbar level, and patients are usually older than 50 years, with a long history of back pain. The cord signal abnormality can involve a very long segment. Look for a serpiginous flow void along the cord surface.

Intervention

Medicolegal Pitfalls

Abnormal spinal cord lesions do not always represent neoplasms. A repeat examination should always be considered in suspicious cases.
Careful review of the patient's medical history and an evaluation of the brain with MRI can prove helpful in the diagnosis, especially in young females.

Multimedia

Media file 1: Sagittal, T2-weighted magnetic resonance image of the cervical spinal cord in a 27-year-old woman showing a fusiform area of increased signal intensity representing a multiple sclerosis plaque. Same patient as in Image 2.

Media file 2: Corresponding axial, T2-weighted magnetic resonance image in a 27-year-old woman showing a multiple sclerosis plaque located in the left dorsolateral region of the left hemicord. Same patient as in Image 1.

Media file 3: Sagittal, T2-weighted image showing areas of signal hyperintensity in the cervical spinal cord and pons. Same patient as in Images 4-5.

Media file 4: Corresponding axial, T2-weighted image showing a large area of signal hyperintensity in the right lateral aspect of the cord. Same patient as in Images 3 and 5.

Media file 5: Sagittal, T1-weighted image following gadolinium contrast showing arciform enhancement along the edge of the plaque, typical of demyelination. Same patient as in Images 3-4.

Media file 6: Gadolinium-enhanced, T1-weighted image showing enhancement of the left optic nerve (arrow). Same patient as in Image 7.

Media file 7: Corresponding axial images of the spinal cord showing enhancing plaque (arrow). The combination of optic neuritis and spinal cord lesion constitutes Devic neuromyelitis optica. Same patient as in Image 6.

Media file 8: Sagittal, T2-weighted image showing a focal area of spinal cord atrophy in a patient with long-standing multiple sclerosis.

References

Noseworthy JH, Lucchinetti C, Rodriguez M, et al. Multiple sclerosis. N Engl J Med. Sep 28 2000;343(13):938-52. [Medline].
Rosati G. The prevalence of multiple sclerosis in the world: an update. Neurol. Sci. 2001;22 (2):117–39. [Medline].
Parry-Jones AR, Mitchell JD, Gunarwardena WJ, et al. Leber's hereditary optic neuropathy associated with multiple sclerosis: Harding's syndrome. Pract Neurol. Apr 2008;8(2):118-21. [Medline].
Grossman RI, Yousem DM. Neuroradiology: The Requisites. St Louis, Mo: Mosby-Year Book; 1994.
Rovira-Canellas A, Alonso-Farre J, Rio-Izquierdo J. [Magnetic resonance in the clinical and therapeutic follow-up of multiple sclerosis]. Rev Neurol. May 16-31 2000;30(10):980-5. [Medline].
Agosta F, Absinta M, Sormani MP, et al. In vivo assessment of cervical cord damage in MS patients: a longitudinal diffusion tensor MRI study. Brain. Aug 2007;130:2211-9. [Medline].
LM Tartaglino, DP Friedman, AE Flanders, et al. Multiple sclerosis in the spinal cord: MR appearance and correlation with clinical parameters. Radiology. 1995;Vol 195:725-32. [Medline]. [Full Text].
Filippi M. Enhanced magnetic resonance imaging in multiple sclerosis. Mult Scler. Oct 2000;6(5):320-6. [Medline].
Grossman RI, Barkhof F, Filippi M. Assessment of spinal cord damage in MS using MRI. J Neurol Sci. Jan 15 2000;172 Suppl 1:S36-9. [Medline].
Henning A, Schär M, Kollias SS, et al. Quantitative magnetic resonance spectroscopy in the entire human cervical spinal cord and beyond at 3T. Magn Reson Med. Apr 17 2008;[Medline].
Marliani AF, Clementi V, Albini-Riccioli L, et al. Quantitative proton magnetic resonance spectroscopy of the human cervical spinal cord at 3 Tesla. Magn Reson Med. Jan 2007;57(1):160-3. [Medline].
Filippi M, Yousry TA, Alkadhi H, et al. Spinal cord MRI in multiple sclerosis with multicoil arrays: a comparison between fast spin echo and fast FLAIR. J Neurol Neurosurg Psychiatry. Dec 1996;61(6):632-5. [Medline]. [Full Text].
Hittmair K, Mallek R, Prayer D, et al. Spinal cord lesions in patients with multiple sclerosis: comparison of MR pulse sequences. AJNR Am J Neuroradiol. Sep 1996;17(8):1555-65. [Medline]. [Full Text].
Stevenson VL, Gawne-Cain ML, Barker GJ, et al. Imaging of the spinal cord and brain in multiple sclerosis: a comparative study between fast FLAIR and fast spin echo. J Neurol. Feb 1997;244(2):119-24. [Medline].
Filippi M, Bozzali M, Horsfield MA, et al. A conventional and magnetization transfer MRI study of the cervical cord in patients with MS. Neurology. Jan 11 2000;54(1):207-13. [Medline].
Finelli DA, Hurst GC, Karaman BA, et al. Use of magnetization transfer for improved contrast on gradient-echo MR images of the cervical spine. Radiology. Oct 1994;193(1):165-71. [Medline]. [Full Text].
Rocca MA, Mastronardo G, Horsfield MA, et al. Comparison of three MR sequences for the detection of cervical cord lesions in patients with multiple sclerosis. AJNR Am J Neuroradiol. Oct 1999;20(9):1710-6. [Medline]. [Full Text].
Poonawalla AH, Hou P, Nelson FA, et al. Cervical spinal cord lesions in multiple sclerosis: T1-weighted inversion-recovery MR imaging with phase-sensitive reconstruction. Radiology. Jan 2008;246(1):258-64. [Medline]. [Full Text].

Keywords

MS, demyelinating process, brain lesions, spine lesions, perivenular inflammation, plaques, fibrillary gliosis, oligodendroglia, spinal MS, spinal multiple sclerosis, Devic neuromyelitis optica, optic neuritis

Contributor Information and Disclosures

Author

Djamil Fertikh, MD, Attending Physician, Division of Radiology, Association of Alexandria Radiologists
Djamil Fertikh, MD is a member of the following medical societies: American College of Radiology, American Medical Association, and Radiological Society of North America
Disclosure: Nothing to disclose

Coauthor

Michael L Brooks, MD, JD, FCLM, Clinical Associate Professor of Radiology, Philadelphia College of Osteopathic Medicine; Director of Neuroradiology, Mercy Diagnostic Imaging, Department of Radiology, Mercy Fitzgerald Hospital
Michael L Brooks, MD, JD, FCLM is a member of the following medical societies: American College of Legal Medicine, American College of Radiology, American Society of Neuroradiology, American Society of Pediatric Neuroradiology, and American Society of Spine Radiology
Disclosure: Nothing to disclose

Medical Editor

Mahesh R Patel, MD, Chief of MRI, Department of Radiology, Santa Clara Valley Medical Center
Mahesh R Patel, MD is a member of the following medical societies: Radiological Society of North America
Disclosure: Nothing to disclose

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose

Managing Editor

Val Runge, MD, Robert and Alma Moreton Centennial Chair in Radiology, Professor, Editor-in-Chief of Investigative Radiology, Department of Radiology, Scott and White Clinic and Hospital
Val Runge, MD is a member of the following medical societies: Society for Health and Human Values
Disclosure: Nothing to disclose

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose

Chief Editor

James G Smirniotopoulos, MD, Professor of Radiology, Neurology, and Biomedical Informatics, Chairman, Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences
James G Smirniotopoulos, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Head and Neck Radiology, American Society of Neuroradiology, American Society of Pediatric Neuroradiology, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose

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Rebecca Wertman, , BA, Ersan Altun, Diego R. Martin, Donald G. Mitchell, John R. Leyendecker, Ryan B. O''Malley, Daniel J. Parsons, Edwin R. Fuller III, Richard C. Semelka
Sep 1, 2008; 248:799-806
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Management of the Incidental Renal Mass

2009-02-01T14:55:00.001-08:00

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Management of the Incidental Renal Mass

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Stuart G. Silverman, Gary M. Israel, Brian R. Herts, Jerome P. Richie
Oct 1, 2008; 249:16-31

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Lumbar Degenerative Disk Disease

2009-02-01T14:52:00.003-08:00

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Ectopic Pregnancy

2009-02-01T14:52:00.001-08:00

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Deborah Levine
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Incidental Adrenal Lesions: Principles, Techniques, and Algorithms for Imagi...

2009-02-01T14:51:00.005-08:00

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Incidental Adrenal Lesions: Principles, Techniques, and Algorithms for Imaging Characterization

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MR Arthrography of the Hip: Differentiation between an Anterior Sublabral Re...

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MR Arthrography of the Hip: Differentiation between an Anterior Sublabral Recess as a Normal Variant and a Labral Tear

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Lumbar Spine: Reliability of MR Imaging Findings

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Giant Cell Tumor

2009-01-31T11:42:00.001-08:00

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Persistent pain and swelling over the left ring finger metacarpophalangeal joint are present in a 28-year-old woman later diagnosed with a giant cell tumor. What is the preferred imaging modality?
Applied Radiology

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Testicular Microlithiasis

2009-01-29T14:04:00.001-08:00

Testicular Microlithiasis

Michelle Townsend-Watts, MD; Ian Karol, MD; Arthur Pinto, MD Appl Radiol. 2008;37(12):34-36. �2008 Anderson Publishing, Ltd.

Posted 01/29/2009

Summary

A 37-year-old man presented with a complaint of a rapidly enlarging testicular mass that had occurred over a 2-week period. There was no reported history of antecedent trauma, pain, or discomfort.

On physical examination, the patient was found be a healthy man with no palpable abdominal or inguinal masses. Upon examination of the left testicle, a moderate testicular mass was palpated. The contralateral right testicle and epididymis were normal.

Imaging Findings

Ultrasound revealed bilateral micro lithiasis of the testicles. The left testicle was found to have an underlying 4-cm solid, hypoechoic, mildly lobulated soft tissue mass that was most suggestive of a neoplasm in a sea of microlithiasis (Figure 1). CT of the abdomen was performed and showed a few small retroperitoneal lymph nodes of moderate suspicion (Figure 2).

Figure 1.

(A) Sagittal ultrasound (US) image reveals a lobulated hypoechoic mass within the left testicle and peripheral microlithiasis. (B) Doppler US interrogation shows flow within the seminoma on this sagittal US image of the contralateral (right) testicle. (C) Sagittal US image of the contralateral (right) testicle depicts microlithiasis on a background of normal parenchyma.

Figure 2.

This contrast-enhanced CT scan shows a retroperitoneal lymph node anterior to the left psoas muscle.

The specimen radiograph was quite extraordinary and confirmed innumerable microcalcifications throughout the specimen (Figure 3). Surgical pathology confirmed a classic seminoma of the left testicle. Associated pathologic findings indicated multiple foci of small, scattered, round calcifications (Figures 4 and 5). The differential diagnosis of an intratesticular mass includes neoplasm, especially given the patient's clinical history. However, an inflammatory or infectious process (such an abscess) or a granulomatous process (such as a sarcoid) may also be diagnostic possibilities. Correlation with appropriate clinical history would be helpful in differentiating among these entities.

Figure 3.

The specimen radiograph of the left orchiectomy specimen reveals innumerable microliths.

Figure 4.

This photograph of the bisected specimen reveals the testicular mass.

Figure 5.

(A) Hematoxylin and eosin (H&E)-stained section shows a microlith surrounded by seminiferous tubules. (B) This H&E stained section indicates seminoma of the classic type.

Diagnosis

Testicular microlithiasis (TM) and classic seminoma

Discussion

It is estimated that in the United States in 2007 there were approximately 7920 newly diagnosed cases of testicular cancer, and approximately 380 men died of this disease.^[1] In the 15- to 35-year-old age group, this is the most common cancer in young men and is one of the most responsive to treatment. Testicular cancer remains one of the most common causes of cancer mortality in young men. The only other causes of death that supersede testicular cancer in young men are trauma and suicide.

In 1970, Priebe and Garret^[2] first described testicular microlithiasis in the X-ray of a healthy 4-year-old boy. In 1982, Ikinger et al^[3] identified the association of microcalcifications with testicular cancer. Subsequent description via ultrasonography was described for the first time in 1987 by Doherty et al.^[4] In 1988, Martin et al^[5] reported the association of ultrasound diagnosis of microlithiasis with associated testicular neoplasia.

Testicular microlithiasis is an abnormality of uncertain etiology that is characterized pathologically by the accumulation of smooth round lamellated bodies within the seminiferous tubules.^[6] The microliths are typically scattered diffusely throughout the parenchyma, and range in size from 1 to 3 mm. They typically do not exhibit shadowing, and symmetric involvement has been noted. Two classic categories of microlithiasis have been described. Classic testicular microlithiasis (CTM) is defined as having =5 microliths within a single ultrasound image.^[7] This is in contradistinction to limited microlithiasis (LTM), which doesn't fit into this arbitrary classification.

The prevalence of TM in a referred population has been reported to be approximately 0.6%. A study of the prevalence of microlithiasis in an asymptomatic screening population illustrated that TM occurs in approximately 5% of asymptomatic men.^[8] The association of microlithiasis with testicular cancer in select series has been as high as 40%.^[9]

There are 2 histologic subtypes of microlithiasis reported. One type thought to be secondary to rapid cell turnover is a hematoxylin body consisting of amorphous calcified debris. This subtype is thought to have a greater association with germ cell tumor.^[10] The second subtype is the classically described subtype, which is used throughout the literature and is composed of laminated calcifications that are reported to be associated with cryptorchid testes, germ cell tumors, and otherwise normal testicles. The pathogenesis of TM is unclear. Sertoli cells are responsible for the phagocytosis of intratubular debris. The microcalcifications are thought to result from a defect in this process. It is not known whether microlithiasis leads to subsequent tumor development or if it is part of a spectrum of abnormalities that eventually leads to carcinogenesis.^[9]

There are a number of entities associated with TM, including cryptorchidism, Down's syndrome, infertility, pulmonary microlithiasis, and germ cell tumor. The known associations of microcalcifications in the presence of other known malignancies (such as breast cancer and thyroid cancer) make the association with testicular cancer valid. Intraepithelial germ cell neoplasia (which is also known as carcinoma in situ [CIS]), from which testicular cancer develops, has also been associated with TM. One series reported a 40-fold increase in CIS in men with bilateral TM microlithiasis compared with those patients without TM.^[11] An additional study reported a high prevalence of CIS in a subset of patients with known microlithiasis and a contralateral testicular carcinoma.^[12] Given the 50% probability that CIS will eventually progress into cancer, it is reasonable to perform biopsy of the contralateral testicle in patients with known microlithiasis who are already undergoing a radical orchiectomy for testicular carcinoma.^[10]

Interestingly, Peterson and coworkers refute the theory that microlithiasis is associated with subsequent development of cancer in an asymptomatic screening population.^[8] Their study reported an increased incidence in African American men, a population not at increased risk for testicular cancer in the absence of microlithiasis. Additionally, the rate of carcinoma found in association with TM did not exceed the rate at which it was found in patients who did not have TM.^[8]

Despite the controversy, enough of an association has been established that physical examination with annual screening sonography is recommended. Other authors have recommended that an initial chest and abdominal CT be performed when TM is diagnosed, with continued annual sonographic surveillance.^[13] In a screened population, in addition to excluding a focal mass, clinicians should be alerted to subtle alteration in the echotexture of the testicular parenchyma, which may suggest the early manifestations of germ cell neoplasia.

Conclusion

Testicular cancer is the most common cancer in young men aged 15 to 35 and is typically responsive to treatment. Although testicular microlithiasis is relatively rare, it is historically associated with testicular cancer. Controversy still exists on recommendations for future follow-up of incidental testicular microlithiasis. This radiologic case reinforces the importance of remaining cognizant of the association between the 2 conditions. Diligent sonographic interrogation of the testes in the setting of microlithiasis is essential, as illustrated by this case.

References

American Cancer Society. Cancer Facts and Figures 2007. Available on the ACS Web site at http://www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf. Accessed October 2008.
Priebe CJ Jr, Garret R. Testicular calcification in a 4-year-old boy. Pediatrics. 1970;46:785-788.
Ikinger U, Wurster K, Terwey B, M�hring K. Microcalcifications in testicular malignancy: Diagnostic tool in occult tumor? Urology. 1982;19:525-528.
Doherty FJ, Mullins TL, Sant GR, et al. Testicular microlithiasis. A unique sonographic appearance.J Ultrasound Med. 1987;6:389-392.
Martin B, Tubiana J. Signficance of scrotal calcifications detected by sonography. J Clin Ultrasound. 1988;16:545-552.
Patel MD, Olcott EW, Kerschmann RL, et al. Sonographically detected testicular microlithiasis and testicular carcinoma. J Clin Ultrasound. 1993;21:447-452.
Bennett HF, Middleton WD, Bullock AD, Teefey SA. Testicular microlithiasis: US follow-up. Radiology. 2001;218:359-363.
Peterson AC, Bauman JM, Light DE, et al. The prevalence of testicular microlithiasis in an asymptomatic population of men 18 to 35 years old. J Urol. 2001;166:2061-2064.
Woodward PJ, Sohaey R, O'Donoghue MJ, Green D. From the archives of the AFIP. Tumors and tumorlike lesions of the testis: Radiologic-pathologic correlation. RadioGraphics. 2002;22:189-216. Comment in: J Urol. 2003;169:1599.
Bach AM, Hann LE, Hadar O, et al. Testicular microlithiasis: What is its association with testicular cancer? Radiology. 2001;220:70-75. Comment in: Radiology. 2002;223:582-583; author reply 583-584.
de Gouveia Brazao CA, Pierik FH, Oosterhuis JW, et al. Bilateral testicular microlithiasis predicts the presence of the precursor of testicular germ cell tumors in subfertile men.J Urol. 2004;171:158-60.
Holme M, Hoei-Hansen CE, Rajpert-DeMeyts E. Increased risk of carcinoma in situ in patients with testicular germ cell cancer with ultrasonic microlithiasis in the contralateraltesticle. J Urol. 2003;170: 1163-1167.
Bach AM, Hann LE, Shi W, et al. Is there an increased incidence of contralateral testicular cancer in patients with intratesticular microlithiasis? AJR Am J Roentgenol. 2003;180:497-500. Comment in: J Urol. 2003;170:1040-1041.

Primary Breast Cancer in Men Has Unique Imaging Features

2009-01-08T14:51:00.001-08:00

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Primary Breast Cancer in Men Has Unique Imaging Features

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Men who develop primary breast cancer usually present with an irregular subareolar mass with speculated or indistinct margins on mammography, according to a report in the December issue of the American Journal of Radiology.
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A Case of Maternal Herpes Simplex Virus Encephalitis During Late Pregnancy

2009-01-08T14:50:00.001-08:00

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A Case of Maternal Herpes Simplex Virus Encephalitis During Late Pregnancy

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This article presents the case of a pregnant woman with maternal herpes and discusses strategies for treating the virus.
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CT Angiography Excels as "Rule-Out" Test But Overestimates Disease Severity,...

2008-12-16T18:51:00.001-08:00

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CT Angiography Excels as "Rule-Out" Test But Overestimates Disease Severity, Study Shows

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CT advocates say being able to rule out disease is the true value of a screening test, but others see the high false-positive rate with CTA as a recipe for soaring healthcare costs and unnecessary add-on tests.
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Clinical Management of Small Polyps Detected at Screening CT Colonography

2008-12-16T00:37:00.000-08:00

Clinical Management of Small Polyps Detected at Screening CT Colonography