A randomized, non-comparative phase 2 study of neoadjuvant immune-checkpoint blockade in retroperitoneal dedifferentiated liposarcoma and extremity/truncal undifferentiated pleomorphic sarcoma

Based on the demonstrated clinical activity of immune-checkpoint blockade (ICB) in advanced dedifferentiated liposarcoma (DDLPS) and undifferentiated pleomorphic sarcoma (UPS), we conducted a randomized, non-comparative phase 2 trial ( NCT03307616 ) of neoadjuvant nivolumab or nivolumab/ipilimumab in patients with resectable retroperitoneal DDLPS (n = 17) and extremity/truncal UPS (+ concurrent nivolumab/radiation therapy; n = 10). The primary end point of pathologic response (percent hyalinization) was a median of 8.8% in DDLPS and 89% in UPS. Secondary end points were the changes in immune infiltrate, radiographic response, 12- and 24-month relapse-free survival and overall survival. Lower densities of regulatory T cells before treatment were associated with a major pathologic response (hyalinization > 30%). Tumor infiltration by B cells was increased following neoadjuvant treatment and was associated with overall survival in DDLPS. B cell infiltration was associated with higher densities of regulatory T cells before treatment, which was lost upon ICB treatment. Our data demonstrate that neoadjuvant ICB is associated with complex immune changes within the tumor microenvironment in DDLPS and UPS and that neoadjuvant ICB with concurrent radiotherapy has significant efficacy in UPS.

Parosteal osteosarcoma of the temporal bone: Case report

Parosteal osteosarcomas (POS) are well-differentiated low-grade malignant sarcomas that are located on the surface of the bone. POS of the temporal bone is exceptionally rare, with less than a hand full of cases present in modern literature. Here, we report a POS of the temporal bone found incidentally and with an uncharacteristic presentation. We also review the unique imaging and histopathological findings of this entity and discuss why developing a broad differential diagnosis and proceeding with early intervention are considered imperative in this disease.

The lateral forearm flap versus traditional upper extremity flaps: A comparison of donor site morbidity and flap thickness

INTRODUCTION

The lateral forearm flap (LFF) is a thin fasciocutaneous flap with a donor site that can be closed primarily.

METHODS

A retrospective analysis of donor site morbidity and hand function was performed in patients who underwent a radial forearm flap (RFF), ulnar artery perforator flap (UAPF), or LFF. Flap thickness was evaluated radiographically in 50 control patients.

RESULTS

Of 134 patients (lateral forearm flap: n = 49, RFF: n = 47, UAPF: n = 38), the LFF demonstrated significantly faster return to baseline hand grip strength (3 months vs. 12 months in RFF and UAPF; p < 0.001), had significantly fewer donor site complications (6.1% compared to 6.4% in RFF and 28.9% in UAPF; p = 0.003) and fewer sensory deficits (2.0% compared to 6.4% in RFF and 15.8% in UAPF sites; p = 0.013). The radiographic study confirmed the LFF to be the thinnest of all upper extremity flap options.

CONCLUSIONS

The LFF is an excellent forearm-based flap option with thin, pliable tissue and low donor site morbidity.

Parosteal Osteosarcoma of the skull: Pathophysiological and imaging review

Parosteal Osteosarcoma (POS) is a well-differentiated low-grade malignant sarcoma occurring at the bone surface. POS of the skull is exceedingly rare, with only 4 temporal bone cases reported in modern literature. This tumor may resemble a multitude of entities, hence identifying it is critical. This may be achieved through a combination of clinical, histopathological, and imaging diagnostic techniques. POS may recur locally or dedifferentiate, the latter having a worse prognosis. This review aims to update the reader regarding the management of the rare Parosteal Osteosarcoma located in the skull bone.

An association between exposure to Middle East Respiratory Syndrome (MERS) and mortality rate of Coronavirus Disease 2019 (COVID-19)

OBJECTIVE

Our objective was to find an association between exposure of a population to Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and mortality rate due to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) across different countries worldwide.

MATERIALS AND METHODS

To find the relationship between exposure to MERS-CoV and mortality rate due to SARS-CoV-2, we collected and analyzed data of three possible factors that may have resulted in an exposure of a population to MERS-CoV: (1) the number of Middle East Respiratory Syndrome (MERS) cases reported among 16 countries since 2012; (2) data of MERS-CoV seroprevalence in camels across 23 countries, as working with camels increase risk of exposure to MERS-CoV; (3) data of travel history of people from 51 countries to Saudi Arabia was collected on the assumption that travel to a country where MERS is endemic, such as, Saudi Arabia, could also lead to exposure to MERS-CoV.

RESULTS

We found a significantly lower number of Coronavirus disease 2019 (COVID-19) deaths per million (deaths/M) of a population in countries that are likely to be exposed to MERS-CoV than otherwise (t-stat=3.686, p<0.01). In addition, the number of COVID-19 deaths/M of a population was significantly lower in countries that reported a higher seroprevalence of MERS-CoV in camels than otherwise (t-stat=4.5077, p<0.01). Regression analysis showed that increased travelling history to Saudi Arabia is likely to be associated with a lower mortality rate due to COVID-19.

CONCLUSIONS

This study provides empirical evidence that a population that was at an increased risk of exposure to MERS-CoV had a significantly lower mortality rate due to SARS-CoV-2, which might be due to cross-protective immunity against SARS-CoV-2 in that population because of an earlier exposure to MERS-CoV.

Multiple Myeloma: Role of Imaging in Diagnosis, Staging, and Treatment Response Assessment

Multiple myeloma is a common hematologic malignancy of plasma cells. Differentiating multiple myeloma from the precursor stages of monoclonal gammopathy of undetermined significance and smoldering multiple myeloma is very important because the treatment approach is different for each. The diagnosis is mainly clinical, while the role of imaging is confined to the staging process, assessing response to therapy, and monitoring for disease progression. In this article, we examine the role of different imaging modalities in patients with multiple myeloma.

Desmoid fibromatosis following surgical resection of spinal meningioma

A 42-year-old female patient with a history of cervicothoracic junction meningioma World Health Organization grade I, resected in early 2011, was admitted to the hospital with intractable headache and lower extremity weakness. Magnetic resonance imaging (MRI) showed an epidural mass compressing the spinal cord at the prior surgical site, which was interpreted as recurrent meningioma. Following surgical resection, histopathological analysis revealed desmoid fibromatosis (desmoid tumor). In retrospect, dynamic contrast-enhanced magnetic resonance imaging performed prior to surgery should have allowed for prospective exclusion of meningioma as the recurrent mass and suggested an alternative diagnosis such as post-traumatic desmoid fibromatosis or the need for biopsy to confirm diagnosis.

Imaging features of adrenal gland masses in the pediatric population

The spectrum of adrenal masses in the pediatric population markedly differs from that in the adult population. Imaging plays a crucial role in detecting adrenal masses, differentiating malignant from benign lesions, recognizing extra-adrenal lesions in the suprarenal fossa, and directing further management. Ultrasound is the primary imaging modality of choice for the evaluation of adrenal masses in the neonatal period, whereas MRI or CT is used as a problem-solving tool. In older children, computed tomography or magnetic resonance imaging is often required after initial sonographic evaluation for further characterization of a lesion. Herein, we discuss the salient imaging features along with pathophysiology and clinical features of pediatric adrenal masses.

The Postoperative Pancreas Imaging

Recent advances in the surgical techniques and postoperative intensive care have led to a decrease in the mortality rates after major pancreatic procedures, which now ranges from 1 to 3%. However, the morbidity rates are still high, resulting in longer hospital stays and greater cost. Imaging plays a fundamental role in the postoperative assessment. Specially, multidetector computed tomography scans (MDCT) is the modality of choice in the postoperative settings. Early diagnosis of the postoperative complications and differentiating them from being normal or expected postoperative findings is crucial to offer the best possible care for patients and to decrease the morbidity and mortality associated with surgery. In this article, we will briefly review the normal pancreatic anatomy, discuss the main types of pancreatic surgeries, and illustrate the imaging findings during the early postoperative period and of the main postsurgical complications in both acute and chronic postoperative settings.

Imaging in pediatric ovarian tumors

The spectrum of ovarian tumors in the pediatric population differs significantly from that in adults. Germ cell tumors are the predominant class of ovarian tumors in children, whereas epithelial tumors are the most common in adults. Ultrasonography is the modality of choice for the initial evaluation of pediatric ovarian tumors. Determining the diagnosis based on imaging may prove difficult, and combining the imaging findings with the clinical scenario is very helpful in reaching a differential diagnosis during clinical practice. We will discuss the spectrum of ovarian neoplasms in the pediatric population and describe their clinical, pathologic, and imaging characteristics. A few unique entities related to ovarian tumors, such as growing teratoma syndrome, anti-N-methyl-D-aspartate receptor encephalitis, and hereditary ovarian tumor syndromes, are also discussed. In addition, we will review several entities that may mimic ovarian neoplasms as well as their distinct imaging features.

Pancreatic Cancer Imaging: What the Surgeon Wants to Know?

Pancreatic cancer is rare but is one of the deadliest cancers. Complete surgical removal of the cancer with negative margins is the only potentially curative treatment. However, majority of the cases present with distant metastases and/or locally advanced disease, and only a limited subset (up to 20%) of patients are surgical candidates. Therefore, accurate staging of pancreatic cancer is very important for treatment planning. It is very important to distinguish between patients who are surgical candidates and those who would need palliative treatment. Imaging plays a crucial role in the detection of the primary tumor, vascular involvement and variants, metastasis, prediction of resectability, and monitoring treatment response. High-resolution multidetector computed tomography (CT) is the primary imaging modality of choice for diagnosing and staging pancreatic cancers. Nevertheless, integration of ultrasound, CT, and magnetic resonance imaging (MRI) may be needed for accurate determination of the tumor extent and optimal management. Herein, we aim to provide a radiological review for “what the surgeon wants to know about pancreatic cancer?” In this review, we highlight the main types of invasive pancreatic cancers and discuss the role of imaging in determining the resectability of pancreatic tumors and the role of neoadjuvant treatment in downstaging borderline or unresectable cases in addition to featuring significant postsurgical complications.

Myxoid Liposarcoma With Skeletal Metastases: Pathophysiology and Imaging Characteristics

Liposarcoma is a commonly occurring soft tissue sarcoma that can be divided into 4 subtypes. Myxoid and round cell liposarcoma (MRCL) represent one of these subtypes and are classified together due to their shared chromosomal translocation. Histologic analysis of MRCL reveals a myxoid matrix with a delicate capillary network and dispersed lipoblasts. Varying degrees of round cell component are also observed, with greater amounts of round cells indicating a higher histologic grade and poorer prognosis. MRCL has a unique pattern of spread due to its initial tendency to spread to extrapulmonary sites. Additionally, skeletal metastases are frequently found in cases of MRCL. While various imaging techniques are used to visualize MRCL and metastases, magnetic resonance imaging is generally the preferred method. This article reviews the pathophysiology and imaging features of MRCL as well as the imaging characteristics, advantages, and drawbacks of multiple imaging modalities for visualizing bone metastases.

The lumbar artery perforator flap: clinical review and guidance on image reporting

The lumbar artery perforator (LAP) flap is a relatively new procedure that can be utilized to manage lumbosacral defects in addition to reconstructing distal body parts as well, such as breast reconstruction. This fasciocutaneous flap is designed based on the LAPs small arteries that emerge from the lumbar arteries then move superficially piercing overlying tissues to perforate the lumbar fascia and supply the skin and subcutaneous tissue; However, anatomical and clinical studies regarding the LAP flap and its perforators are sparse in the literature, and the results are even contradicting. This article will discuss the LAP flap, the anatomy of its perforators, and the clinical aspects about its usage. In addition, we explore its preoperative imaging evaluation, and deliver a guide on image reporting and radiological data that will benefit the surgeon most during the procedure.

Calcified leiomyoma of the deltoid: pathophysiology and imaging review

Leiomyomas are benign tumors of smooth muscle cells. Leiomyomas of somatic soft tissue are a specific class of leiomyoma believed to arise from the smooth muscle cells found in the walls of blood vessels and represent less than 4% of benign, somatic soft tissue tumors. Of the somatic soft tissue tumors, approximately one-third will become calcified. We report an intramuscular, calcified leiomyoma arising from the left deltoid of a 47-year-old Caucasian male. To the best of the authors' knowledge, this is the first reported case of a calcified, intramuscular leiomyoma of the deltoid. Imaging studies and patient presentation were initially suggestive of tumoral calcinosis or myositis ossificans. It was not until pathologic examination that the correct diagnosis of the calcified leiomyoma was made. Leiomyoma should be included in the differential diagnosis of calcified soft tissue masses. If excised with adequate margins, recurrence is unlikely.

Primary Osteosarcoma of the Breast: Pathophysiology and Imaging Review

Extraskeletal osteosarcoma are rare malignant mesenchymal neoplasms of soft tissues representing around 1% of all soft tissue. The exact mechanism of tumorigenesis of primary breast osteosarcoma is still unclear. However, most of the cases develop without a recognized etiologic factor. Primary osteosarcoma of the breast is often initially misdiagnosed as breast fibroadenoma. Different imaging modalities and pathology play important role in differentiating breast osteosarcoma from other benign and malignant lesions of the breast resulting in dramatic change in the management.

Consultation and citation rates for prior imaging studies and documents in radiology

Frequently, the consensus conclusion after quality assurance conferences in radiology is that whatever mistake was made could have been avoided if more prior images or documents had been consulted. It is generally assumed that anything that was not specifically cited in the report had not been consulted. Is it actually safe to assume that an image or document that is not cited was also not consulted? It is this question that this investigation addresses. In this Institutional Review Board-approved study, one observer watched the board-certified radiologists while they interpreted imaging studies and issued reports. He recorded what type of study was being interpreted [either computed tomography, magnetic resonance imaging, or conventional radiography (x-ray)]. He also recorded the number and type of prior imaging studies and documents that were consulted during the interpretation. These observations were then compared with the signed report to determine how many of the consulted imaging studies and documents were cited. Of the 198 previous imaging studies that the radiologists consulted, 116 (58.6%) were cited in a report. Of the 285 documents consulted, 3 (1.1%) were cited in a report. This difference in citation rate was statistically significant (p<0.0001). It cannot be safely assumed that an older radiologic image or medical document was not consulted during radiologic interpretation merely because it is not cited in the report. Radiologists often consult more old studies than they cite, and they do not cite the majority of prior documents that they consult.