Objectives
Vertebral invasion is a key prognostic factor and a critical aspect of surgical planning for superior sulcus tumors. This study aims to further evaluate MRI features of vertebral invasion ...in order to distinguish it from reactive inflammatory changes.
Methods
Between 2000 and 2016, a retrospective study was performed at a single institution. All patients with superior sulcus tumors undergoing surgery, including at least two partial vertebrectomies, were included. An expert radiologist evaluated qualitative and quantitative MRI signal intensity characteristics (contrast-to-noise ratio CNR) of suspected involved and non-involved vertebrae. A comparison of CNR of invaded and sane vertebrae was performed using non-parametric tests. Imaging data were correlated with pathological findings.
Results
A total of 92 surgical samples of vertebrectomy were analyzed. The most specific sequences for invasion were T1 and T2 weighted (92% and 97%, respectively). The most sensitive sequences were contrast enhanced T1 weighted fat suppressed and T2 weighted fat suppressed (100% and 80%). Loss of extrapleural paravertebral fat on the T1-weighted sequence was highly sensitive (100%) but not specific (63%). Using quantitative analysis, the optimum cut-off (
p
< 0.05) to distinguish invasion from reactive inflammatory changes was CNR > 11 for the T2-weighted fat-sat sequence (sensitivity 100%), CNR > 9 for contrast-enhanced T1-weighted fat-suppressed sequence (sensitivity 100%), and CNR < − 30 for the T1-weighted sequence (specificity 97%). Combining these criteria, 23 partial vertebrectomies could have been avoided in our cohort.
Conclusion
Qualitative and quantitative MRI analyses are useful to discriminate vertebral invasion from reactive inflammatory changes.
Key Points
• Abnormal signal intensity in a vertebral body adjacent to a superior sulcus tumor may be secondary to direct invasion or reactive inflammatory changes.
• Accurate differentiation between invasion and reactive inflammatory changes significantly impacts surgical planning. T1w and T2w are the best sequences to differentiate malignant versus benign bone marrow changes. The use of quantitative analysis improves MRI specificity.
• Using contrast media improves the sensitivity for the detection of tumor invasion.
Backgrounds
Multivisceral resection is the standard treatment for retroperitoneal sarcoma (RPS) during which pancreas resection may be necessary.
Methods
All consecutive patients operated for RPS ...with pancreatectomy in 2 expert centers between 1993 and 2018 were retrospectively analyzed.
Results
Fifty patients (median age: 57 years, IQR: 46–65) with a primary (
n
= 33) or recurrent (
n
= 17) RPS underwent surgery requiring pancreas resection (distal pancreatectomy (DP) (
n
= 43), pancreaticoduodenectomy (PD) (
n
= 5), central pancreatectomy (
n
= 1), and atypical resection (
n
= 1)). Severe postoperative morbidity (Clavien-Dindo III–IV) was observed in 14 patients (28%), and 7 of them (14%) required reoperation for anastomotic bowel leakage (
n
= 5), gastric volvulus (
n
= 1), or hemorrhage (
n
= 1). Pancreas-related complications occurred in 25 patients (50%): 10 postoperative pancreatic fistulas (POPF) (grade A (
n
= 12), grade B (
n
= 6), grade C (
n
= 1)), 13 delayed gastric emptying (grade A (
n
= 8), grade B (
n
= 4), grade C (
n
= 1)), 1 hemorrhage (grade C). Postoperative mortality was 4% (
n
= 2), all following PD, caused by a massive intraoperative air embolism and by a multiple organ failure after anastomotic leakage. Pathological analysis confirmed pancreatic involvement in 17 (34%) specimens. Microscopically complete resection (R0) was achieved in 22 (44%) patients. After a follow-up of 60 months, 36 patients (75%) were still alive, among whom 27 without recurrence (56%).
Conclusion
Pancreatic resection during RPS surgery is associated with significant postoperative morbidity and mortality. PD should be avoided whenever possible while other procedures seemed achievable without excessive morbidity and with long-term survival.
In numerous countries, large population testing is impossible due to the limited availability of RT-PCR kits and CT-scans. This study aimed to determine a pre-test probability score for SARS-CoV-2 ...infection.
This multicenter retrospective study (4 University Hospitals) included patients with clinical suspicion of SARS-CoV-2 infection. Demographic characteristics, clinical symptoms, and results of blood tests (complete white blood cell count, serum electrolytes and CRP) were collected. A pre-test probability score was derived from univariate analyses of clinical and biological variables between patients and controls, followed by multivariate binary logistic analysis to determine the independent variables associated with SARS-CoV-2 infection.
605 patients were included between March 10th and April 30th, 2020 (200 patients for the training cohort, 405 consecutive patients for the validation cohort). In the multivariate analysis, lymphocyte (<1.3 G/L), eosinophil (<0.06 G/L), basophil (<0.04 G/L) and neutrophil counts (<5 G/L) were associated with high probability of SARS-CoV-2 infection but no clinical variable was statistically significant. The score had a good performance in the validation cohort (AUC = 0.918 (CI: 0.891-0.946; STD = 0.014) with a Positive Predictive Value of high-probability score of 93% (95%CI: 0.89-0.96). Furthermore, a low-probability score excluded SARS-CoV-2 infection with a Negative Predictive Value of 98% (95%CI: 0.93-0.99). The performance of the score was stable even during the last period of the study (15-30th April) with more controls than infected patients.
The PARIS score has a good performance to categorize the pre-test probability of SARS-CoV-2 infection based on complete white blood cell count. It could help clinicians adapt testing and for rapid triage of patients before test results.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objectives
Synovial sarcomas (SS) of the extremities are rare soft tissue sarcomas that are more common in young adults. We deciphered the imaging phenotype of SS with the aim to determine if imaging ...could provide an incremental value to currently known prognostic factors (PF)—age and histological grade—to predict long-term overall survival (OS).
Methods
This retrospective multicenter study included consecutive pediatric and adult patients with synovial sarcomas of the extremities from December 2002 to August 2020. Inclusion criteria were (i) a follow-up greater than 5 years and (ii) available pre-therapeutic MRI. A subset analysis included MRI and CT-scan. Clinical, pathological, and imaging variables were collected in all patients. The primary endpoint was to evaluate the association of these variables with OS using univariate and multivariate Cox regressions.
Results
Out of 428 patients screened for eligibility, 98 patients (mean age: 37.1 ± 15.2 years) were included (MRI:
n
= 98/98, CT scan:
n
= 34/98; 35%). The median OS was 75.25 months (IQR = 55.50–109.12) and thirty-six patients (
n
= 36/98;37%) died during follow-up. The recurrence rate was 12.2% (
n
=12/98). SS lesions were mostly grade 2 (57/98; 58%). On MRI, SS had a mean long-axis diameter of 67.5 ± 38.3 mm. On CT scan, 44% (15/34) were calcified. Grade (hazard ratio HR = 2.71; 95%CI = 1.30–5.66;
p
= 0.008), size of the lesions evaluated on MRI (HR = 1.02; 95% CI = 1.01–1.03;
p
< 0.001), and calcifications on CT scan (HR = 0.10; 95% CI = 0.02–0.50;
p
= 0.005) were independent PF of OS.
Conclusions
This study demonstrated that imaging biomarkers can be used to predict long-term outcome in patients with SS. Strikingly, the presence of calcifications on CT scan is associated with favorable outcome and provides an incremental value over existing PF such as age, grade, and size.
Key points
• Beyond its diagnostic value, MRI is a pre-operative prognostic tool in synovial sarcomas of the extremities since the size of the lesion is an important prognostic factor.
• Calcifications on CT scans are independently and significantly associated with prolonged overall survival.
Covid-19 pneumonia CT extent correlates well with outcome including mortality. However, CT is not widely available in many countries. This study aimed to explore the relationship between Covid-19 ...pneumonia CT extent and blood tests variations. The objective was to determine for the biological variables correlating with disease severity the cut-off values showing the best performance to predict the parenchymal extent of the pneumonia.
Bivariate correlations were calculated between biological variables and grade of disease extent on CT. Receiving Operating Characteristic curve analysis determined the best cutoffs for the strongest correlated biological variables. The performance of these variables to predict mild (<10%) or severe pneumonia (>50% of parenchyma involved) was evaluated.
Correlations between biological variables and disease extent was evaluated in 168 patients included in this study. LDH, lymphocyte count and CRP showed the strongest correlations (with 0.67, −0.41 and 0.52 correlation coefficient, respectively). Patients were split into a training and a validation cohort according to their centers. If one variable was above/below the following cut-offs, LDH>380, CRP>80 or lymphocyte count <0.8G/L, severe pneumonia extent on CT was detected with 100% sensitivity. Values above/below all three thresholds were denoted in 73% of patients with severe pneumonia extent. The combination of LDH<220 and CRP<22 was associated with mild pneumonia extent (<10%) with specificity of 100%.
LDH showed the strongest correlation with the extent of Covid-19 pneumonia on CT. Combined with CRP±lymphocyte count, it helps predicting parenchymal extent of the pneumonia when CT scan is not available.
•Patients with mild respiratory symptoms are not necessarily referred for CT when they are diagnosed with SARS-CoV2 infection.•Previous studies demonstrated than extent of Covid-19 pneumonia on CT is related to patients' outcome.•LDH combined with CRP and lymphocyte count, help predicting parenchymal extent of the pneumonia when CT-scan is not available.
Criteria based on measurements of lesion diameter at CT have guided treatment with historical therapies due to the strong association between tumor size and survival. Clinical experience with immune ...checkpoint modulators shows that editing immune system function can be effective in various solid tumors. Equally, novel immune-related phenomena accompany this novel therapeutic paradigm. These effects of immunotherapy challenge the association of tumor size with response or progression and include risks and adverse events that present new demands for imaging to guide treatment decisions. Emerging and evolving approaches to immunotherapy highlight further key issues for imaging evaluation, such as dissociated response following local administration of immune checkpoint modulators, pseudoprogression due to immune infiltration in the tumor environment, and premature death due to hyperprogression. Research that may offer tools for radiologists to meet these challenges is reviewed. Different modalities are discussed, including immuno-PET, as well as new applications of CT, MRI, and fluorodeoxyglucose PET, such as radiomics and imaging of hematopoietic tissues or anthropometric characteristics. Multilevel integration of imaging and other biomarkers may improve clinical guidance for immunotherapies and provide theranostic opportunities.
Traditionally, transforaminal steroid injection is performed in the management of cervical radiculopathy in medical failure treatment but carried a true risk of catastrophic complication. Another ...approach currently used is to perform intra-articular facet steroid injection to reach the epidural space.
The aim of this study was to describe the evolution of symptoms following intra-articular facet steroid injection in cervical radiculopathy.
We conducted a retrospective study. We assessed all patients who had a CT-guided intra-articular facet steroid injection in our center (xx, xx, xx) from December 2015 to February 2021. Cervical MR pretherapeutic images were analyzed and classified according to cervical pain etiology: uncodiscarthrosis, disk herniation or congestive cervical posterior osteo-arthritis. All patients had clinical initial evaluation and then follow-up at 1 and 6 months. Pain severity was rated on a visual analog scale and expressed as a percentage of improvement.
Ninety-three patients were included. There were 56 patients with uncodiscarthrosis, 29 with a disk herniation and 8 with a cervical posterior congestive osteoarthritis. A significant improvement of the visual analog scale percentage was found for all patient at 1 and 6 months (p < 0.01). Visual analog scale percentage improvement was about 50 % for all etiologies. For all patients, no severe complications were reported.
Intra-articular facet steroid injection may be considered for the treatment of cervical radiculopathy when other medical treatments have failed.
Objectives
We aimed to compare the reliability and performance of MRI measures enhanced with intravenous (IV) injection of gadolinium contrast versus non-enhanced MRI measures for the diagnosis of ...adhesive capsulitis (AC). We also aimed to examine the association between MRI findings and clinical features in patients with AC.
Methods
MRI of 42 patients with a clinical diagnosis of AC confirmed by arthrography and that of 42 patients in a control group were retrospectively studied by 2 blinded readers. Reliability and performance of MRI findings were compared between IV contrast-enhanced measures and non-enhanced MRI measures in T2-weighted fat-saturated and T1-weighted images. MRI findings were correlated with clinical stage, etiology, and pain.
Results
Sensitivity (97.6%) and specificity (97.6%) of axillary-recess capsule signal enhancement for AC diagnosis were significantly superior (
p
= 0.02) to hyperintense signals on T2-weighted fat-suppressed images (sensitivity 90.5%, specificity 92.7%). Measures of the intensity signal in the area of the rotator interval were less performant for AC diagnosis but could be improved with joint capsule enhancement. Moreover, we found very high specificity (100%) of enhancement of the coracohumeral ligament signal for AC diagnosis. The early stage of adhesive capsulitis was positively correlated with joint capsule enhancement in the rotator interval. Secondary etiology of capsulitis was correlated with joint capsule hyperintensity signals of the rotator interval on T2-weighted fat-suppressed images.
Conclusion
IV contrast injection with MRI can be helpful for AC diagnosis in difficult cases. The stage of AC seems related to joint capsule enhancement in the rotator interval.
Key Points
•
IV gadolinium-enhanced MRI can improve the analysis of signal changes in the shoulder synovium and capsule of the shoulder that are related to adhesive capsulitis.
•
As an original finding, we observed that coracohumeral ligament enhancement had a 100% specificity for the diagnosis of adhesive capsulitis.
•
The intensity of enhanced signals in the rotator interval seems to be related to the early stage of frozen shoulder.
Objective
To describe clinical and early shoulder-girdle MR imaging findings in severe COVID-19–related intensive care unit-acquired weakness (ICU-AW) after ICU discharge.
Methods
A single-center ...prospective cohort study of all consecutive patients with COVID-19–related ICU-AW from November 2020 to June 2021. All patients underwent similar clinical evaluations and shoulder-girdle MRI within the first month and then 3 months (± 1 month) after ICU discharge.
Results
We included 25 patients (14 males; mean SD age 62.4 12.5). Within the first month after ICU discharge, all patients showed severe proximal predominant bilateral muscular weakness (mean Medical Research Council total score = 46.5/60 10.1) associated with bilateral, peripheral muscular edema-like MRI signals of the shoulder girdle in 23/25 (92%) patients. At 3 months, 21/25 (84%) patients showed complete or quasi-complete resolution of proximal muscular weakness (mean Medical Research Council total score > 48/60) and 23/25 (92%) complete resolution of MRI signals of the shoulder girdle, but 12/20 (60%) patients experienced shoulder pain and/or shoulder dysfunction.
Conclusions
Early shoulder-girdle MRI findings in COVID-19–related ICU-AW included muscular edema-like peripheral signal intensities, without fatty muscle involution or muscle necrosis, with favorable evolution at 3 months. Precocious MRI can help clinicians distinguish critical illness myopathy from alternative, more severe diagnoses and can be useful in the care of patients discharged from intensive care with ICU-AW.
Key Points
•
We describe the clinical and shoulder-girdle MRI findings of COVID-19–related severe intensive care unit-acquired weakness.
•
This information can be used by clinicians to achieve a nearly specific diagnosis, distinguish alternative diagnoses, assess functional prognosis, and select the more appropriate health care rehabilitation and shoulder impairment treatment.
Objectives
To evaluate post-ablation MRI for the detection of incompletely treated spinal osseous metastases (SOM) after cryoablation and to propose a post-ablation imaging classification.
Methods
...After IRB consent, all patients treated with cryoablation of SOM between 2011 and 2017 having at least 1-year minimum follow-up and a spine MRI within 4 months after cryoablation were retrospectively included. A classification of MRI images into four types was set up. The primary endpoint of our study was to assess the diagnostic performance of the post-ablation MRI. The secondary endpoints were the 1-year complete treatment rate (CTR) and complications.
Results
Fifty-four SOMs in 39 patients were evaluated. Post-ablation MRI was performed with a median delay of 25 days after cryoablation. Images were evaluated by two independent readers according to the pre-established image classification. Sensitivity and specificity for the detection of residual tumor were 77.3% (95%CI = 62.2–88.5) and 85.9% (95%CI = 75.0–93.4), respectively. Types I, II, III, and IV of the classification were associated with a 1-year complete treatment in 100%, 83.3%, 35.7%, and 10% of cases, respectively. The 1-year CTR was 59.3% for all 54 metastases, and 95.8% for metastases measuring less than 25 mm and at least 2 mm or more away from the spinal canal. Two grade 3 and two grade 2 adverse events according to the CTCAE were reported.
Conclusions
MRI after cryoablation is useful for the evaluation of the ablation efficacy. The classification of post-cryoablation MRI provides reliable clues for the prediction of complete treatment at 1 year.
Key Points
• MRI performed 25 days after cryoablation is useful to evaluate the efficacy.
• The proposed classification provides a reliable clue for complete cryoablation.
• Percutaneous cryoablation of spinal metastases is highly effective for lesions less than 25 mm in diameter and of at least 2 mm away from the spinal canal.
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