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Souza FF, D’Amato G, Jonczak EE, Costa P, Trent JC, Rosenberg AE, Yechieli R, Temple HT, Pattany P, Subhawong TK. MRI T2 mapping assessment of T2 relaxation time in desmoid tumors as a quantitative imaging biomarker of tumor response: preliminary results. Front Oncol 2023; 13:1286807. [PMID: 38188297 PMCID: PMC10766853 DOI: 10.3389/fonc.2023.1286807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/17/2023] [Indexed: 01/09/2024] Open
Abstract
Objectives Because size-based imaging criteria poorly capture biologic response in desmoid-type fibromatosis (DF), changes in MRI T2 signal intensity are frequently used as a response surrogate, but remain qualitative. We hypothesized that absolute quantification of DF T2 relaxation time derived from parametric T2 maps would be a feasible and effective imaging biomarker of disease activity. Methods This IRB-approved retrospective study included 11 patients with DF, managed by observation or systemic therapy, assessed by 3T MRI. Tumor maximum diameter, volume, and T2-weighted signal intensity were derived from manual tumor segmentations. Tumor:muscle T2 signal ratios were recorded. Two readers measured tumor T2 relaxation times using a commercial T2 scanning sequence, manual ROI delineation and commercial calculation software enabling estimation of reader reliability. Objective response rates based on RECIST1.1 and best responses were compared between size-based and signal-based parameters. Results Median patient age was 52.6 years; 8 subjects were female (73%). Nine patients with longitudinal assessments were followed for an average of 314 days. Median baseline tumor diameter was 7.2 cm (range 4.4 - 18.2 cm). Median baseline T2 was 65.1 ms (range 40.4 - 94.8 ms, n=11); median at last follow-up was 44.3 ms (-32% from baseline; range 29.3 - 94.7 ms, n=9). T2 relaxation times correlated with tumor:muscle T2 signal ratios, Spearman p=0.78 (p<0.001). T2 mapping showed high inter-reader reliability, ICC=0.84. The best response as a percentage change in T2 values was statistically significant (mean -17.9%, p=0.05, paired t-test) while change in diameter was not (mean -8.9%, p=0.12). Conclusions Analysis of T2 relaxation time maps of DF may offer a feasible quantitative biomarker for assessing the extent of response to treatment. This approach may have high inter-reader reliability.
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Affiliation(s)
- Felipe F. Souza
- Department of Radiology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, United States
| | - Gina D’Amato
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, United States
- Department of Internal Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Emily Elizabeth Jonczak
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, United States
- Department of Internal Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Philippos Costa
- Department of Internal Medicine, Yale Medicine, New Haven, CT, United States
| | - Jonathan C. Trent
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, United States
- Department of Internal Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Andrew E. Rosenberg
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, United States
- Department of Pathology & Laboratory Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Raphael Yechieli
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, United States
- Department of Radiation Oncology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - H. Thomas Temple
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, United States
- Department of Orthopaedics, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Pradip Pattany
- Department of Radiology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Ty K. Subhawong
- Department of Radiology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, United States
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Magoon S, Peters V, de Souza FF, Chen D, Owens P, Pretell‐Mazzini J, Fullerton N, Jose J, Rosenberg A, Subhawong TK. Hand and finger, ultrasound-guided, percutaneous core needle biopsies: A safe procedure with high diagnostic accuracy. Australas J Ultrasound Med 2023; 26:243-248. [PMID: 38098613 PMCID: PMC10716568 DOI: 10.1002/ajum.12365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023] Open
Abstract
Introduction/Purpose To determine the diagnostic accuracy and complication rates of ultrasound-guided, percutaneous core needle biopsies of soft tissue masses in the hand and fingers. Methods Reports from all ultrasound-guided procedures between 21 May 2014 and 17 March 2022 were queried for keywords including "hand", OR "finger", AND "biopsy". Patient demographics, lesion size and location, biopsy needle gauge and the number of cores obtained were recorded. The final pathology of the mass excision was then compared with the core needle biopsy (CNB) for each patient. Results Sixty-six records were reviewed, and 37 patients met inclusion criteria. Maximum lesion diameter averaged 1.45 cm with a range between 0.4 and 4.3 cm. The frequency of needle gauges used was 14G (14%), 16G (24%), 18G (38%), 20G (11%) and 'not reported' (14%). The mean number of tissue cores obtained was 2.9 (SD 1.2; range 1 to 6), excluding nine cases that reported 'multiple'. The frequency of CNB diagnoses included tenosynovial giant cell tumour (TGCT) at 30%, ganglion cyst at 11% and epidermal inclusion cyst at 5%. CNB was 100% sensitive in detecting the three (8%) malignancies. Of the 37 tumours biopsied, 16 were surgically excised. One angiomyoma was originally diagnosed as a haemangioma on CNB, but all other histologic results were concordant for a diagnostic accuracy of 97%. Discussion Small soft tissue masses in the hands and fingers, even those less than 1 cm, are often amenable to ultrasound-guided CNB. Performance under image guidance facilitates retrieval of core specimens adquate for histologic diagnosis with relatively few passes using higher gauge needles. Conclusion Overall, ultrasound-guided CNB of the hand and fingers is safe and highly accurate in diagnosing soft tissue tumours. The accuracy is unrelated to the needle's gauge, the number of passes and the size of the lesions.
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Affiliation(s)
- Stephanie Magoon
- Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
| | - Vanessa Peters
- Leonard M. Miller School of Medicine, University of MiamiMiamiFloridaUSA
| | - Felipe Ferreira de Souza
- Department of RadiologyUniversity of Miami Miller School of Medicine and the Sylvester Comprehensive Care CenterMiamiFloridaUSA
| | - David Chen
- Department of Orthopedic SurgeryUniversity of Miami Miller School of Medicine and the Sylvester Comprehensive Care CenterMiamiFloridaUSA
| | - Patrick Owens
- Department of Orthopedic SurgeryUniversity of Miami Miller School of Medicine and the Sylvester Comprehensive Care CenterMiamiFloridaUSA
| | - Juan Pretell‐Mazzini
- Department of OrthopedicsHerbert Wertheim College of Medicine, Florida International UniversityMiamiFloridaUSA
| | - Natalia Fullerton
- Department of Plastic SurgeryUniversity of Miami Miller School of Medicine and the Sylvester Comprehensive Care CenterMiamiFloridaUSA
| | - Jean Jose
- Department of RadiologyUniversity of Miami Miller School of Medicine and the Sylvester Comprehensive Care CenterMiamiFloridaUSA
| | - Andrew Rosenberg
- Department of PathologyUniversity of Miami Miller School of Medicine and the Sylvester Comprehensive Care CenterMiamiFloridaUSA
| | - Ty K. Subhawong
- Department of RadiologyUniversity of Miami Miller School of Medicine and the Sylvester Comprehensive Care CenterMiamiFloridaUSA
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Castillo-Flores S, Gonzalez MR, Bryce-Alberti M, de Souza F, Subhawong TK, Kuker R, Pretell-Mazzini J. PET-CT in the Evaluation of Neoadjuvant/Adjuvant Treatment Response of Soft-tissue Sarcomas: A Comprehensive Review of the Literature. JBJS Rev 2022; 10:01874474-202212000-00003. [PMID: 36639875 DOI: 10.2106/jbjs.rvw.22.00131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
➢ In soft-tissue sarcomas (STSs), the use of positron emission tomography-computed tomography (PET-CT) through a standardized uptake value reduction rate correlates well with histopathological response to neoadjuvant treatment and survival. ➢ PET-CT has shown a better sensitivity to diagnose systemic involvement compared with magnetic resonance imaging and CT; therefore, it has an important role in detecting recurrent systemic disease. However, delaying the use of PET-CT scan, to differentiate tumor recurrence from benign fluorodeoxyglucose uptake changes after surgical treatment and radiotherapy, is essential. ➢ PET-CT limitations such as difficult differentiation between benign inflammatory and malignant processes, inefficient discrimination between benign soft-tissue tumors and STSs, and low sensitivity when evaluating small pulmonary metastases must be of special consideration.
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Affiliation(s)
- Samy Castillo-Flores
- Medical Student at Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Marcos R Gonzalez
- Medical Student at Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Mayte Bryce-Alberti
- Medical Student at Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Felipe de Souza
- Division of Musculoskeletal Radiology, Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Ty K Subhawong
- Division of Musculoskeletal Radiology, Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Russ Kuker
- Division of Musculoskeletal Radiology, Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan Pretell-Mazzini
- Division of Orthopedic Oncology, Miami Cancer Institute, Baptist Health System South Florida, Plantation, Florida
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Nathenson MJ, Hu J, Ratan R, Somaiah N, Hsu R, DeMaria PJ, Catoe HW, Pang A, Subhawong TK, Amini B, Sweet K, Feister K, Malik K, Jagannathan J, Braschi-Amirfarzan M, Sheren J, Caldas Y, Moreno Tellez C, Rosenberg AE, Lazar AJ, Maki RG, Benedetto P, Cohen J, Trent JC, Ravi V, Patel S, Wilky BA. Systemic Chemotherapies Retain Antitumor Activity in Desmoid Tumors Independent of Specific Mutations in CTNNB1 or APC: A Multi-institutional Retrospective Study. Clin Cancer Res 2022; 28:4092-4104. [PMID: 35180772 PMCID: PMC9475245 DOI: 10.1158/1078-0432.ccr-21-4504] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/23/2022] [Accepted: 02/16/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Determine whether specific CTNNB1 or APC mutations in patients with desmoid tumor were associated with differences in clinical responses to systemic treatments. EXPERIMENTAL DESIGN We established a multi-institutional dataset of previously treated patients with desmoid tumor across four U.S. sarcoma centers, including demographic and clinicopathologic characteristics, treatment regimens, and clinical and radiographic responses. CTNNB1 or APC mutation status was determined from prior pathology records, or archival tissue was requested and analyzed by Sanger sequencing and/or next-generation sequencing. Evaluable patients with mutation results were analyzed to determine clinical progression-free survival (cPFS), RECIST 1.1 PFS (rPFS), time to next treatment (TTNT), and overall survival (OS). Kaplan-Meier analysis and Cox proportional hazards regression were performed to identify differences in cPFS, rPFS, TTNT, and OS by mutation subtype, desmoid tumor location, and treatment regimen. RESULTS A total of 259 evaluable patients were analyzed for at least one of the survival outcomes, with 177 patients having mutation data. First- and second-line cPFS, rPFS, and TTNT were not significantly affected by mutation subtype; however, APC-mutant desmoid tumors demonstrated nonstatistically significant inferior outcomes. Extremity/trunk desmoid tumor location and treatment with doxorubicin-based, methotrexate/vinca alkaloids and sorafenib regimens were associated with better clinical outcomes compared with surgery or "other" therapies, including estrogen-receptor blockade and imatinib. OS was significantly worse with APC or CTNNB1 negative/other mutations. CONCLUSIONS Mutation subtype did not affect responses to specific systemic therapies. APC mutations and nonextremity desmoid tumor locations remain prognostic for worse outcomes, and earlier initiation of systemic therapy for these higher-risk desmoid tumors should be prospectively evaluated. See related commentary by Greene and Van Tine, p. 3911.
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Affiliation(s)
- Michael J. Nathenson
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Junxiao Hu
- Department of Biostatistics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ravin Ratan
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Neeta Somaiah
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert Hsu
- Department of Medicine, University of Miami School of Medicine, Miami, Florida
| | - Peter J. DeMaria
- Department of Medicine, University of Miami School of Medicine, Miami, Florida
| | - Heath W. Catoe
- Department of Medicine, University of Miami School of Medicine, Miami, Florida
| | - Angela Pang
- Department of Medicine, Mount Sinai School of Medicine, New York, New York
| | - Ty K. Subhawong
- Department of Radiology, University of Miami School of Medicine, Miami, Florida
| | - Behrang Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kevin Sweet
- Department of Radiology, University of Miami School of Medicine, Miami, Florida
| | - Katharina Feister
- Department of Radiology, University of Miami School of Medicine, Miami, Florida
| | - Karan Malik
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Jyothi Jagannathan
- Department of Imaging, Dana-Farber Cancer Institute, Harvard Medical School, and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marta Braschi-Amirfarzan
- Department of Imaging, Dana-Farber Cancer Institute, Harvard Medical School, and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jamie Sheren
- Department of Pathology, University of Colorado School of Medicine, Aurora, Colorado
| | - Yupanqui Caldas
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Cristiam Moreno Tellez
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Andrew E. Rosenberg
- Department of Pathology, University of Miami School of Medicine, Miami, Florida
| | - Alexander J. Lazar
- Department of Pathology and Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert G. Maki
- Department of Medicine, Mount Sinai School of Medicine, New York, New York
| | - Pasquale Benedetto
- Department of Medicine, University of Miami School of Medicine, Miami, Florida
| | - Jonathan Cohen
- Department of Medicine, University of Miami School of Medicine, Miami, Florida
| | - Jonathan C. Trent
- Department of Medicine, University of Miami School of Medicine, Miami, Florida
| | - Vinod Ravi
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shreyaskumar Patel
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Breelyn A. Wilky
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Alidina S, Alidina J, Souza F, Kalandiak S, Subhawong TK. Radiographic Evaluation of Elbow Fractures. Semin Musculoskelet Radiol 2021; 25:529-537. [PMID: 34706382 DOI: 10.1055/s-0041-1731083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Fractures and dislocations of the elbow are a common cause of emergency department visits each year. Radiography remains the bedrock of an initial injury assessment, and recognition of distinctive injury patterns based on fracture location, morphology, and severity, guides optimal clinical decision-making. This article reviews basic elbow anatomy, frequently seen fractures and injury patterns, and highlights how these findings influence surgical planning and patient management.
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Affiliation(s)
- Sameer Alidina
- University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Jasim Alidina
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Felipe Souza
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Steven Kalandiak
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
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Finkelstein D, Foremny G, Singer A, Clifford P, Pretell-Mazzini J, Kerr DA, Subhawong TK. Differential diagnosis of T2 hypointense masses in musculoskeletal MRI. Skeletal Radiol 2021; 50:1981-1994. [PMID: 33651128 DOI: 10.1007/s00256-021-03711-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 02/02/2023]
Abstract
Many soft tissue masses have an indeterminate appearance on MRI, often displaying varying degrees and extent of T2 hyperintensity. However, a subset of neoplasms and tumor-like lesions may exhibit prominent areas of T2 hypointensity relative to skeletal muscle. The hypointensity observed on T2-weighted MRI can be caused by a variety of substances, including evolving blood products, calcifications or other inorganic crystals, or fibrous tissue. Carefully evaluating the presence and pattern of T2 hypointensity in soft tissue masses and considering potential causes in their associated clinical contexts can help to narrow the differential diagnosis among neoplastic and non-neoplastic possibilities. These include endometriosis, aneurysmal bone cysts, tenosynovial giant cell tumor, arteriovenous malformation and pseudoaneurysm, calcium pyrophosphate and hydroxyapatite deposition diseases, tumoral calcinosis, gout, amyloidosis, hemangiomas with phleboliths, low-grade fibromyxoid sarcoma, ossifying fibromyxoid tumor, collagenous fibroma, desmoid-type fibromatosis, myxofibrosarcoma, peripheral nerve sheath tumors, dedifferentiated liposarcoma, and treated sarcoma.
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Affiliation(s)
- Dara Finkelstein
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL, 33136, USA
| | - Gregory Foremny
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL, 33136, USA
| | - Adam Singer
- Department of Radiology, Emory University Hospital, Atlanta, GA, 30322, USA
| | - Paul Clifford
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL, 33136, USA
| | - Juan Pretell-Mazzini
- Department of Orthopaedics, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, 33136, USA
| | - Darcy A Kerr
- Department of Pathology, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL, 33136, USA.
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Massel DH, Haziza S, Rivera S, Mohile N, Subhawong TK, Hernandez VH. Septic Arthritis of the Shoulder After SARS-CoV-2 Pfizer Vaccination: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00053. [PMID: 34329200 DOI: 10.2106/jbjs.cc.21.00090] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report a case of a 68-year-old woman who developed left shoulder glenohumeral joint septic arthritis within 1 week of receiving the COVID-19 Pfizer-BioNTech vaccine. CONCLUSION Common vaccine complications include injection site pain, fever, chills, arthralgia, and hypersensitivity reactions. A less common and more serious complication of septic arthritis has been reported and requires invasive treatment of surgical irrigation and debridement, and culture-specific parenteral antibiotic therapy. The current report highlights the clinical presentation and significant potential for serious complication with the improper technique. We urge vaccine administrators to practice caution and aseptic technique when vaccinating patients to reduce the risk of complication and morbidity.
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Affiliation(s)
- Dustin H Massel
- Department of Orthopaedics, University of Miami, Miami, Florida
| | - Sagie Haziza
- Department of Orthopaedics, University of Miami, Miami, Florida
| | | | - Neil Mohile
- Department of Orthopaedics, University of Miami, Miami, Florida
| | - Ty K Subhawong
- Department of Radiology, University of Miami, Miami, Florida
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Subhawong TK, Feister K, Sweet K, Alperin N, Kwon D, Rosenberg A, Trent J, Wilky BA. MRI Volumetrics and Image Texture Analysis in Assessing Systemic Treatment Response in Extra-Abdominal Desmoid Fibromatosis. Radiol Imaging Cancer 2021; 3:e210016. [PMID: 34213370 DOI: 10.1148/rycan.2021210016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To determine whether MRI volumetric and image texture analysis correlates with treatment-induced biologic changes in desmoid fibromatosis (DF) earlier than conventional response criteria. Materials and Methods This retrospective study included 27 patients with histologically proven extra-abdominal DF who were managed with active surveillance or systemic therapy (from 2004 to 2016). MRI volumetric and image texture parameters were derived from manual tumor segmentations, and tumor signal intensity was normalized to muscle. Results were compared with objective response rates based on Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, World Health Organization (WHO) lesion response, volumetrics, and MRI-modified Choi criteria. Correlation coefficients (r) between image texture features and maximum tumor diameters were obtained by using a meta-analysis approach. Results The 27 included patients (mean age, 39 years; 74% women) were followed for an average of 4 years, comprising 207 distinct time-point assessments. The mean baseline tumor maximum diameter was 7.9 cm (range, 3.4-15.2 cm). Partial response (PR) rates as best response were 37%, 44%, 70%, and 81% by RECIST, WHO, volumetrics, and MRI-modified Choi criteria, respectively. Among the 10 tumors showing RECIST PR, a preceding MRI-modified Choi PR was observed in 70% (seven of 10), on average 1.3 years earlier. Multiple image texture parameters showed associations with objective measurements of tumor diameter including mean tumor-to-muscle signal ratio (r = 0.51; P = .004), median tumor-to-muscle signal ratio (r = 0.52; P = .003), energy (r = 0.48; P < .001), run entropy (r = 0.32, P = .04), and gray-level nonuniformity (r = 0.54; P ≤ .001). Conclusion Volumetric signal and image texture assessment allows more comprehensive analysis of DF biologic change and may permit early prediction of DF behavior and therapeutic response. Keywords: MR Imaging, Soft Tissues/Skin, Neoplasms-Primary © RSNA, 2021.
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Affiliation(s)
- Ty K Subhawong
- From the Departments of Radiology (T.K.S., N.A.), Pathology (A.R.), and Medicine-Medical Oncology (J.T., B.A.W.), Sylvester Comprehensive Cancer Center and the University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL 33136; Department of Radiology, University of Miami Miller School of Medicine, Miami, Fla (K.F., K.S.); and Department of Public Health Sciences, Sylvester Biostatistics and Bioinformatics Shared Resource, University of Miami Miller School of Medicine, Miami, Fla (D.K.)
| | - Katharina Feister
- From the Departments of Radiology (T.K.S., N.A.), Pathology (A.R.), and Medicine-Medical Oncology (J.T., B.A.W.), Sylvester Comprehensive Cancer Center and the University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL 33136; Department of Radiology, University of Miami Miller School of Medicine, Miami, Fla (K.F., K.S.); and Department of Public Health Sciences, Sylvester Biostatistics and Bioinformatics Shared Resource, University of Miami Miller School of Medicine, Miami, Fla (D.K.)
| | - Kevin Sweet
- From the Departments of Radiology (T.K.S., N.A.), Pathology (A.R.), and Medicine-Medical Oncology (J.T., B.A.W.), Sylvester Comprehensive Cancer Center and the University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL 33136; Department of Radiology, University of Miami Miller School of Medicine, Miami, Fla (K.F., K.S.); and Department of Public Health Sciences, Sylvester Biostatistics and Bioinformatics Shared Resource, University of Miami Miller School of Medicine, Miami, Fla (D.K.)
| | - Noam Alperin
- From the Departments of Radiology (T.K.S., N.A.), Pathology (A.R.), and Medicine-Medical Oncology (J.T., B.A.W.), Sylvester Comprehensive Cancer Center and the University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL 33136; Department of Radiology, University of Miami Miller School of Medicine, Miami, Fla (K.F., K.S.); and Department of Public Health Sciences, Sylvester Biostatistics and Bioinformatics Shared Resource, University of Miami Miller School of Medicine, Miami, Fla (D.K.)
| | - Deukwoo Kwon
- From the Departments of Radiology (T.K.S., N.A.), Pathology (A.R.), and Medicine-Medical Oncology (J.T., B.A.W.), Sylvester Comprehensive Cancer Center and the University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL 33136; Department of Radiology, University of Miami Miller School of Medicine, Miami, Fla (K.F., K.S.); and Department of Public Health Sciences, Sylvester Biostatistics and Bioinformatics Shared Resource, University of Miami Miller School of Medicine, Miami, Fla (D.K.)
| | - Andrew Rosenberg
- From the Departments of Radiology (T.K.S., N.A.), Pathology (A.R.), and Medicine-Medical Oncology (J.T., B.A.W.), Sylvester Comprehensive Cancer Center and the University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL 33136; Department of Radiology, University of Miami Miller School of Medicine, Miami, Fla (K.F., K.S.); and Department of Public Health Sciences, Sylvester Biostatistics and Bioinformatics Shared Resource, University of Miami Miller School of Medicine, Miami, Fla (D.K.)
| | - Jonathan Trent
- From the Departments of Radiology (T.K.S., N.A.), Pathology (A.R.), and Medicine-Medical Oncology (J.T., B.A.W.), Sylvester Comprehensive Cancer Center and the University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL 33136; Department of Radiology, University of Miami Miller School of Medicine, Miami, Fla (K.F., K.S.); and Department of Public Health Sciences, Sylvester Biostatistics and Bioinformatics Shared Resource, University of Miami Miller School of Medicine, Miami, Fla (D.K.)
| | - Breelyn A Wilky
- From the Departments of Radiology (T.K.S., N.A.), Pathology (A.R.), and Medicine-Medical Oncology (J.T., B.A.W.), Sylvester Comprehensive Cancer Center and the University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL 33136; Department of Radiology, University of Miami Miller School of Medicine, Miami, Fla (K.F., K.S.); and Department of Public Health Sciences, Sylvester Biostatistics and Bioinformatics Shared Resource, University of Miami Miller School of Medicine, Miami, Fla (D.K.)
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Ramachandran A, Fox T, Wolfson A, Banks J, Subhawong TK. Superficial fibromatosis: MRI radiomics and T2 mapping correlate with treatment response. Magn Reson Imaging 2021; 81:53-59. [PMID: 34116132 DOI: 10.1016/j.mri.2021.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/22/2021] [Accepted: 06/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Superficial fibromatosis exhibits variable MR signal intensity due to collagenous and fibroproliferative components. Quantifying this signal heterogeneity using image texture analysis and T2-mapping could have prognostic and therapeutic implications. METHODS This IRB-approved retrospective study included 13 patients with superficial fibromatosis, managed by observation, electron beam radiotherapy (EBT), or pentoxifylline/vitamin E. Two-dimensional regions of interest (ROIs) were drawn on proton-density or T2-weighted MRI for radiomics feature analysis, and corresponding T2-maps. Comparisons were made between baseline and follow-up T2 relaxation times and radiomics features: Shannon's entropy, kurtosis, skewness, mean of positive pixels (MPP), and uniformity of distribution of positive gray-level pixel values (UPP). RESULTS There were 19 nodules in 13 subjects. Mean patient age was 60 years; 62% (8/13) were female; mean follow-up was 9.7 months. Nodule diameter at baseline averaged 18.2 mm (std dev 16.2 mm) and decreased almost 10% to 16.6 mm (p = 0.1, paired t-test). Normalized T2 signal intensity decreased 23% from 0.71 to 0.55 (p = 0.03, paired t-test). T2 relaxation time decreased 16% from 46.5 to 39.1 ms (p < 0.001, paired t-test). Among radiomics features, skewness increased to 0.71 from 0.41 (p = 0.03, paired t-test), and entropy decreased from 8.37 to 8.03 (p = 0.05, paired t-test); differences in other radiomics features were not significant. CONCLUSIONS Radiomics analysis and T2-mapping of superficial fibromatosis is feasible; robust decreases in absolute T2 relaxation time, and changes in image textural features (increased skewness and decreased entropy) offer novel imaging biomarkers of nodule collagenization and maturation.
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Affiliation(s)
- Amrutha Ramachandran
- Department of Radiology, Sylvester Comprehensive Cancer Center, the University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Terry Fox
- Department of Radiology, Sylvester Comprehensive Cancer Center, the University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Aaron Wolfson
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, the University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - James Banks
- Department of Radiology, Nova Southeastern University and IntelliRad Imaging, Miami, FL 33133, USA
| | - Ty K Subhawong
- Department of Radiology, Sylvester Comprehensive Cancer Center, the University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL 33136, USA.
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Richardson ML, Amini B, Beckmann NM, Subhawong TK. Measuring and Teaching Confidence Calibration Among Radiologists: A Multi-Institution Study. J Am Coll Radiol 2020; 17:1314-1321. [PMID: 32739415 DOI: 10.1016/j.jacr.2020.06.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/25/2020] [Accepted: 06/01/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Our purpose was to assess the calibration of resident, fellow, and attending radiologists on a simple image classification task (presence or absence of an anterior cruciate ligament [ACL] tear based on interpretation of sagittal proton density, fat-saturated MR images) and to assess whether teaching residents could improve their calibration. METHODS We created a test containing 30 randomized, sagittal, proton density, fat-saturated MR images of the ACL (15 normal, 15 torn). This test was administered in person to 20 trainees and 3 attendings at one medical center in one state. An online version of the test was given to 23 trainees and 14 attendings from 11 other medical centers in nine other states. Subjects were asked to give their confidence level (0%-100%) that each ACL was torn. RESULTS Cross-sectional data were collected from 60 radiologists (mean time after medical school = 9.3 years, minimum = 1 year, maximum = 36 years). This demonstrated a statistically significant improvement in calibration as a function of increasing experience (P = .020). Longitudinal data were collected from 12 trainees at the start and end of their musculoskeletal radiology rotation, with an intervening review of the primary and secondary signs of ACL tear on MR. A statistically significant improvement in calibration was noted during the rotation (P = .028). CONCLUSIONS Confidence calibration is a promising tool for quality improvement and radiologist self-assessment. Our study showed that calibration loss improves with experience in radiologists tested on a common and clinically important image classification task. We also demonstrated that calibration can be successfully taught to residents over a relatively short period (2-4 weeks).
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Affiliation(s)
| | - Behrang Amini
- Department of Radiology, M.D. Anderson Cancer Center, Houston, Texas
| | | | - Ty K Subhawong
- Department of Radiology, University of Miami Health System, Miami, Florida
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12
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Pham K, Ezuddin NS, Pretell-Mazzini J, Subhawong TK. Small soft tissue masses indeterminate at imaging: histological diagnoses at a tertiary orthopedic oncology clinic. Skeletal Radiol 2019; 48:1555-1563. [PMID: 30903259 DOI: 10.1007/s00256-019-03205-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 02/27/2019] [Accepted: 03/07/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To review histologic diagnoses of soft-tissue masses (STMs) ≤ 2 cm with indeterminate imaging features encountered in musculoskeletal oncology clinic at a tertiary referral center. MATERIALS AND METHODS This was an IRB-approved retrospective review of patients with STMs ≤ 2 cm, referred to our tertiary care orthopedic oncology clinic over 4.75 consecutive years. Maximum diameter was based on imaging measurement by a fellowship-trained musculoskeletal radiologist. Simple lipomas, synovial cysts, metastases, and cases without histologic confirmation were excluded. Patient demographics, tumor imaging features (location, depth, size, and tumor:muscle enhancement and T2 signal ratios), and histology were recorded and compared. RESULTS Mean maximum diameter for 42 trunk/extremity STMs was 1.5 cm (range, 0.7 to 2 cm). Mean age was 48 years (range, 18-83 years). Nine (21%) of the masses were malignant, while 33 (79%) were non-malignant. Thirty-nine (93%) of masses were superficial; 7/39 (18%) of these superficial tumors were malignant. Malignancy was not associated with underlying vessels, tendon, or fascia (p = 0.19). The non-malignant vs. malignant tumor:muscle enhancement ratio was 2.15 vs. 2.32 (p = 0.58) and enhancement coefficient of variation was 0.14 vs. 0.10 (p = 0.29). Most common malignant histologic subtypes were synovial sarcoma (n = 3), fibroblastic/myofibroblastic sarcoma (n = 2), leiomyosarcoma (n = 2), myxofibrosarcoma (n = 1), and angiomatoid fibrous histiocytoma (n = 1). The majority (67%) of non-malignant lesions were: leiomyoma (n = 6), angiomyoma (n = 5), schwannoma (n = 4), benign fibrous histiocytoma (n = 4), and hemangioma (n = 3). CONCLUSIONS At a tertiary musculoskeletal oncology referral clinic, primary STMs ≤ 2 cm with indeterminate imaging features should be managed cautiously despite their small size and/or superficial location.
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Affiliation(s)
- Kevin Pham
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL, 33136, USA
| | - Nisreen S Ezuddin
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL, 33136, USA
| | - Juan Pretell-Mazzini
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL, 33136, USA.
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, 33136, USA.
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13
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Wilky BA, Trucco MM, Subhawong TK, Florou V, Park W, Kwon D, Wieder ED, Kolonias D, Rosenberg AE, Kerr DA, Sfakianaki E, Foley M, Merchan JR, Komanduri KV, Trent JC. Axitinib plus pembrolizumab in patients with advanced sarcomas including alveolar soft-part sarcoma: a single-centre, single-arm, phase 2 trial. Lancet Oncol 2019; 20:837-848. [PMID: 31078463 DOI: 10.1016/s1470-2045(19)30153-6] [Citation(s) in RCA: 225] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/14/2019] [Accepted: 03/14/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND VEGF promotes an immunosuppressive microenvironment and contributes to immune checkpoint inhibitor resistance in cancer. We aimed to assess the activity of the VEGF receptor tyrosine-kinase inhibitor axitinib plus the anti-PD-1 immune checkpoint inhibitor pembrolizumab in patients with sarcoma. METHODS This single-centre, single-arm, phase 2 trial was undertaken at a tertiary care academic medical centre in Miami, FL, USA, and participants were recruited from all over the USA and internationally. Patients were eligible if they were aged 16 years or older, and had histologically confirmed advanced or metastatic sarcomas, including alveolar soft-part sarcoma (ASPS); measurable disease with one site amenable to repeated biopsies; an ECOG performance status of 0-1; and progressive disease after previous treatment with at least one line of systemic therapy (unless no standard treatment existed or the patient declined therapy). The first five patients were enrolled in a lead-in cohort and were given axitinib 5 mg orally twice daily and pembrolizumab 200 mg intravenously for 30 min on day 8 and every 3 weeks for cycles of 6 weeks for up to 2 years. Thereafter, patients received escalating doses of axitinib (2-10 mg) plus flat dose pembrolizumab according to the schedule above. The primary endpoint was 3-month progression-free survival. All patients were evaluable for survival and safety analyses. This study is registered with ClinicalTrials.gov, number NCT02636725, and is closed to accrual. FINDINGS Between April 19, 2016, and Feb 7, 2018, of 36 patients assessed for eligibility, 33 (92%) were enrolled and given study treatment (intention-to-treat population and safety population), 12 (36%) of whom had ASPS. With a median follow-up of 14·7 months (IQR 10·1-19·1), 3-month progression-free survival for all evaluable patients was 65·6% (95% CI 46·6-79·3). For patients with ASPS, 3-month progression-free survival was 72·7% (95% CI 37·1-90·3). The most common grade 3 or 4 treatment-related adverse events included hypertension (five [15%] of 33 patients), autoimmune toxicities (five [15%]), nausea or vomiting (two [6%]), and seizures (two [6%]). Serious treatment-related adverse events occurred in seven (21%) patients, including autoimmune colitis, transaminitis, pneumothorax, haemoptysis, seizures, and hypertriglyceridemia. There were no treatment-related deaths. INTERPRETATION Axitinib plus pembrolizumab has manageable toxicity and preliminary activity in patients with advanced sarcomas, particularly patients with ASPS, warranting further investigation in randomised controlled trials. FUNDING Merck, Pfizer, American Cancer Society, and Sylvester Comprehensive Cancer Center.
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Affiliation(s)
- Breelyn A Wilky
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester Comprehensive Cancer Center, Miami, FL, USA.
| | - Matteo M Trucco
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Vaia Florou
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Wungki Park
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deukwoo Kwon
- Department of Public Health Science, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Eric D Wieder
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Despina Kolonias
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Andrew E Rosenberg
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Darcy A Kerr
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Efrosyni Sfakianaki
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mark Foley
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jaime R Merchan
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Krishna V Komanduri
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Jonathan C Trent
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Singer AD, Younan Y, Saadat V, Umpierrez M, Kesner V, Boulis N, Gonzalez F, Subhawong TK. Performance of an Interactive Upper Extremity Peripheral Nerve Training Module Among Medical Students, Radiology Residents, and Fellows: A Multi-institutional Study. Curr Probl Diagn Radiol 2019; 49:7-11. [PMID: 30639073 DOI: 10.1067/j.cpradiol.2018.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/27/2018] [Accepted: 12/31/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Chronic pain is a common problem and imaging is becoming increasingly utilized in the characterization of peripheral neuropathy, although this topic is not emphasized during medical training. We hypothesized that an electronic module and nerve atlas would be effective in improving comprehension among trainees. MATERIALS AND METHODS In this IRB-approved study, a training module was created that included a side-by-side comparison of normal upper extremity nerves on magnetic resonance imaging and ultrasound (US), with embedded questions and cases, followed by a brief hands-on US scanning session. Thirty volunteers with variable training were enrolled in 1 institution, while 14 volunteers were enrolled in another. Pre- and post-test scores were collected and compared. RESULTS There was a response rate of 100% at both institutions. At the first institution, subjects were divided into 2 groups: group 1 (16 medical students) and group 2 (14 residents/fellows). There was a baseline deficit of knowledge among both groups, with a mean pretest score of 37.5% and 47.5% for group 1 and group 2, respectively (P = 0.017). After module completion, both groups improved with a mean post-test score of 67.2% for group 1 and 76.1% for group 2. At the second institution, there was similar improvement even if the scanning session was not done. CONCLUSIONS Use of an electronic module helps trainees to become more familiar with peripheral nerve imaging, regardless of level of training. Use of the module, even in the absence of hands-on US scanning, results in an improved understanding of this topic.
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Affiliation(s)
- Adam Daniel Singer
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA.
| | - Yara Younan
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA
| | - Vandad Saadat
- Department of Radiology, University of Miami, Miami, FL
| | - Monica Umpierrez
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA
| | - Vita Kesner
- Department of Neurology, Emory University Hospital, Atlanta, GA
| | - Nicholas Boulis
- Department of Neurosurgery, Emory University Hospital, Atlanta, GA
| | - Felix Gonzalez
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA
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Shah SS, Consuegra JM, Subhawong TK, Urakov TM, Manzano GR. Epidemiology and etiology of secondary piriformis syndrome: A single-institution retrospective study. J Clin Neurosci 2019; 59:209-212. [DOI: 10.1016/j.jocn.2018.10.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 09/27/2018] [Accepted: 10/14/2018] [Indexed: 10/28/2022]
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16
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Ezuddin NS, Pretell-Mazzini J, Yechieli RL, Kerr DA, Wilky BA, Subhawong TK. Local recurrence of soft-tissue sarcoma: issues in imaging surveillance strategy. Skeletal Radiol 2018; 47:1595-1606. [PMID: 29785452 DOI: 10.1007/s00256-018-2965-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 04/16/2018] [Accepted: 04/30/2018] [Indexed: 02/02/2023]
Abstract
Soft-tissue sarcomas pose diagnostic and therapeutic challenges to physicians, owing to the large number of subtypes, aggressive tumor biology, lack of consensus on management, and controversy surrounding interval and duration of surveillance scans. Advances in multidisciplinary management have improved the care of sarcoma patients, but controversy remains regarding strategies for surveillance following definitive local control. This review provides an updated, comprehensive overview of the current understanding of the risk of local recurrence of soft-tissue sarcoma, by examining the literature based on features such as histological type and grade, tumor size, and resection margin status, with the aim of helping clinicians, surgeons, and radiologists to develop a tailored approach to local imaging surveillance.
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Affiliation(s)
- Nisreen S Ezuddin
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Avenue, JMH WW 279, Miami, FL, 33136, USA
| | - Juan Pretell-Mazzini
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Raphael L Yechieli
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Darcy A Kerr
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Breelyn A Wilky
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Avenue, JMH WW 279, Miami, FL, 33136, USA.
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17
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Wang L, Pretell-Mazzini J, Kerr DA, Chelala L, Yang X, Jose J, Subhawong TK. MRI findings associated with microscopic residual tumor following unplanned excision of soft tissue sarcomas in the extremities. Skeletal Radiol 2018; 47:181-190. [PMID: 28864832 DOI: 10.1007/s00256-017-2762-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 08/01/2017] [Accepted: 08/11/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION MRI is often used to determine the presence of residual disease following unplanned excisions (UPE) of soft tissue sarcomas (STS). We sought to identify MRI features associated with histologic evidence of residual disease after TBE. MATERIALS AND METHODS This was an IRB-approved retrospective review of 27 patients with R1-type UPE of STS over a 32-month period, with subsequent MRI and TBE. MRI studies were retrospectively evaluated to determine depth of tissue involvement, presence of nodular enhancement, and maximum length of soft tissue edema normalized to extremity size. MRI findings were correlated with histology from unplanned excision and TBE. RESULTS Among the 21 subjects, there were 13 males and 8 females, mean age 58. Eighteen of 21 STS were grade 2 or 3. Deep compartments were involved in 5/21 cases. Original margins were positive in 17/21 UPE, with inadequate margin assessment in the remaining 4 cases. Residual tumor was present at TBE in 11/21 cases; it was found in 4/6 cases with nodular enhancement and 7/15 cases without nodular enhancement (sensitivity = 0.36; specificity = 0.80; PPV = 0.67; NPV = 0.53). Increased extent of soft tissue edema increased the likelihood of residual tumor at TBE (OR = 35.0; 95% CI = 1.6 to 752.7; p = 0.023). CONCLUSION Nodular enhancement is neither sensitive nor specific in predicting residual microscopic tumor in TBE following UPE. Extensive soft tissue edema on MRI after UPE increases the likelihood of finding a residual microscopic tumor, justifying ample margins at TBE and consideration of adjuvant therapy.
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Affiliation(s)
- Lee Wang
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave., JMH WW 279, Miami, FL, 33136, USA
| | - Juan Pretell-Mazzini
- Department of Orthopaedic Surgery, Division of Musculoskeletal Oncology, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Darcy A Kerr
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Lydia Chelala
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave., JMH WW 279, Miami, FL, 33136, USA
| | - Xuan Yang
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Jean Jose
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave., JMH WW 279, Miami, FL, 33136, USA
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave., JMH WW 279, Miami, FL, 33136, USA.
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18
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Banks JS, Wolfson AH, Subhawong TK. T2 signal intensity as an imaging biomarker for patients with superficial Fibromatoses of the hands (Dupuytren's disease) and feet (Ledderhose disease) undergoing definitive electron beam irradiation. Skeletal Radiol 2018; 47:243-251. [PMID: 29085992 DOI: 10.1007/s00256-017-2792-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/28/2017] [Accepted: 10/05/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Electron beam therapy is a definitive radiation treatment option for superficial fibromatoses of the hands and feet. Because objective criteria for treatment response remain poorly defined, we sought to describe changes in electron beam treated lesions on MRI. MATERIALS AND METHODS The study included 1 male and 9 female patients with a total of 37 superficial fibromatoses; average age was 60.7 years. Standard 6 MeV electron beam treatment included 3 Gy per fraction for 10 or 12 treatments using split-course with 3-month halfway break. Pre- and post-treatment MRIs were evaluated to determine lesion size (cm3), T2 signal intensity and contrast enhancement (5-point ordinal scales) by a fellowship trained musculoskeletal radiologist. MRI findings were correlated with clinical response using a composite 1-5 ordinal scale, Karnofsky Performance Scale and patient-reported 10-point visual analog scale for pain. RESULTS Mean volume decreased from 1.5 to 1.2 cm3 (p = 0.01, paired t-test). Mean T2 hyperintensity score decreased from 3.0 to 2.1 (p < 0.0001, Wilcoxon signed-rank). Mean enhancement score available for 22 lesions decreased from 3.8 to 3.0 (p < 0.0001, Wilcoxon signed-rank). Performance scores improved from 78.9 ± 13.7 to 84.6 ± 6.9 (p = 0.007, paired t-test). Pain scores decreased from 3.0 ± 3.3 to 1.1 ± 2.0 (p = 0.0001, paired t-test). Post-treatment T2 signal correlated weakly with performance and pain (Spearman's ρ = -0.37 and 0.16, respectively). CONCLUSIONS MRI is valuable for evaluating patients undergoing electron beam therapy for superficial fibromatoses: higher pretreatment T2 intensity may predict benefit from radiotherapy. T2 hypointensity may be a better marker than size for therapeutic effect.
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Affiliation(s)
- James S Banks
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave. JMH WW 279, Miami, FL, 33136, USA.
| | - Aaron H Wolfson
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, 1400 NW 12th Ave, Miami, FL, 33136, USA
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave. JMH WW 279, Miami, FL, 33136, USA
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Allen CJ, Subhawong TK, Hanna MM, Chelala L, Bullock MR, Schulman CI, Proctor KG. Does Vasopressin Exacerbate Cerebral Edema in Patients with Severe Traumatic Brain Injury? Am Surg 2018. [DOI: 10.1177/000313481808400121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Arginine vasopressin (AVP) is often used as an alternative pressor to catecholamines (CATs). However, unlike CATs, AVP is a powerful antidiuretic that could promote edema. We tested the hypothesis that AVP promoted cerebral edema and/or increased requirements for osmotherapy, relative to those who received CATs, for cerebral perfusion pressure (CPP) management after traumatic brain injury (TBI). This is a retrospective review of 286 consecutive TBI patients with intracranial pressure monitoring at a single institution from September 2008 to January 2015. Cerebral edema was quantitated using CT attenuation in prespecified areas of gray and white matter. Results: To maintain CPP >60 mm Hg, 205 patients required no vasopressors, 41 received a single CAT, 12 received AVP, and 28 required both. Those who required no pressors were generally less injured; required less hyperosmolar therapy and less total fluid; and had lower plasma Na, lower intracranial pressure, less edema, and lower mortality (all P < 0.05). Edema; daily mean, minimum, and maximum Na levels; and mortality were similar with AVP versus CATs, but the daily requirement of mannitol and 3 per cent NaCl were reduced by 45 and 35 per cent (both P < 0.05). In patients with TBI who required CPP therapy, AVP reduced the requirements for hyperosmolar therapy and did not delay resolution or increase cerebral edema compared with CATs.
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Affiliation(s)
- Casey J. Allen
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
| | - Ty K. Subhawong
- Department of Radiology, and, University of Miami Miller School of Medicine, Miami, Florida
| | - Mena M. Hanna
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
| | - Lydia Chelala
- Department of Radiology, and, University of Miami Miller School of Medicine, Miami, Florida
| | - M. Ross Bullock
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Carl I. Schulman
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
| | - Kenneth G. Proctor
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
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Jahed K, Khazai B, Umpierrez M, Subhawong TK, Singer AD. Pitfalls in soft tissue sarcoma imaging: chronic expanding hematomas. Skeletal Radiol 2018; 47:119-124. [PMID: 28887645 DOI: 10.1007/s00256-017-2770-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 08/23/2017] [Accepted: 08/25/2017] [Indexed: 02/02/2023]
Abstract
Solid or nodular enhancement is typical of soft tissue sarcomas although high grade soft tissue sarcomas and those with internal hemorrhage often appear heterogeneous with areas of nonenhancement and solid or nodular enhancement. These MRI findings often prompt an orthopedic oncology referral, a biopsy or surgery. However, not all masses with these imaging findings are malignant. We report the multimodality imaging findings of two surgically proven chronic expanding hematomas (CEH) with imaging features that mimicked sarcomas. A third case of nonenhancing CEH of the lower extremity is also presented as a comparison. It is important that in the correct clinical scenario with typical imaging findings, the differential diagnosis of a chronic expanding hematoma be included in the workup of these patients. An image-guided biopsy of nodular tissue within such masses that proves to be negative for malignancy should not necessarily be considered discordant. A correct diagnosis may prevent a morbid unnecessary surgery and may indicate the need for a conservative noninvasive follow-up with imaging.
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Affiliation(s)
- Kiarash Jahed
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA, USA
| | - Behnaz Khazai
- Department of Radiology, University of Miami, Miami, FL, USA.
| | - Monica Umpierrez
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA, USA
| | - Ty K Subhawong
- Department of Radiology, University of Miami, Miami, FL, USA
| | - Adam D Singer
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA, USA
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Allen CJ, Subhawong TK, Hanna MM, Chelala L, Bullock MR, Schulman CI, Proctor KG. Does Vasopressin Exacerbate Cerebral Edema in Patients with Severe Traumatic Brain Injury? Am Surg 2018; 84:43-50. [PMID: 29428027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
UNLABELLED Arginine vasopressin (AVP) is often used as an alternative pressor to catecholamines (CATs). However, unlike CATs, AVP is a powerful antidiuretic that could promote edema. We tested the hypothesis that AVP promoted cerebral edema and/or increased requirements for osmotherapy, relative to those who received CATs, for cerebral perfusion pressure (CPP) management after traumatic brain injury (TBI). This is a retrospective review of 286 consecutive TBI patients with intracranial pressure monitoring at a single institution from September 2008 to January 2015. Cerebral edema was quantitated using CT attenuation in prespecified areas of gray and white matter. RESULTS To maintain CPP >60 mm Hg, 205 patients required no vasopressors, 41 received a single CAT, 12 received AVP, and 28 required both. Those who required no pressors were generally less injured; required less hyperosmolar therapy and less total fluid; and had lower plasma Na, lower intracranial pressure, less edema, and lower mortality (all P < 0.05). Edema; daily mean, minimum, and maximum Na levels; and mortality were similar with AVP versus CATs, but the daily requirement of mannitol and 3 per cent NaCl were reduced by 45 and 35 per cent (both P < 0.05). In patients with TBI who required CPP therapy, AVP reduced the requirements for hyperosmolar therapy and did not delay resolution or increase cerebral edema compared with CATs.
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22
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Subhawong TK, Winn A, Shemesh SS, Pretell-Mazzini J. F-18 FDG PET differentiation of benign from malignant chondroid neoplasms: a systematic review of the literature. Skeletal Radiol 2017; 46:1233-1239. [PMID: 28608242 DOI: 10.1007/s00256-017-2685-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 04/24/2017] [Accepted: 05/24/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Discriminating among benign chondroid tumors, low-grade chondrosarcomas, and grade 2/3 chondrosarcomas is frequently difficult with standard imaging modalities. We systematically reviewed the literature to determine the performance of PET-CT in making this distinction. METHODS A systematic review was performed identifying 811 PubMed- and Embase-indexed articles containing combinations of "chondrosarcoma," "enchondroma," "chondroid," "cartilage" and "PET/CT," "PET," "positron." Eight articles including 166 lesions were included. Age, gender, tumor size, histologic grade, and SUVmax values were extracted for individual lesions when possible and otherwise recorded as aggregated data. Comparisons in SUVmax among benign, low-grade, and intermediate-/high-grade chondroid neoplasms were made. RESULTS Individual SUVs were available for 101 lesions; 65 additional lesions were reported as aggregated data. There were 101 malignant and 65 benign tumors. Benign tumors were seen more frequently in females (p = 0.04, Fischer's exact test), but malignancy was not associated with age or lesion size. SUVmax was lower for benign (1.6 ± 0.7) than malignant tumors (4.4 ± 2.5) (p < 0.0001, t-test). SUVmax was lower for grade 0/1 (2.0 ± 0.7) than grade 2/3 (6.0 ± 3.2) (p < 0.0001, t-test). Increasing SUVmax correlated with higher grade chondroid tumors (Spearman's rank, ρ = 0.78). SUVmax ≥4.4 was 99% specific for grade 2/3 chondrosarcoma. CONCLUSIONS SUVmax correlates with histologic grade in intraosseous chondroid neoplasms; very low SUVmax supports a diagnosis of benign tumor, while elevated SUVmax is suggestive of higher grade chondrosarcoma.
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Affiliation(s)
- Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave., JMH WW 279, Miami, FL, 33136, USA.
| | - Aaron Winn
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave., JMH WW 279, Miami, FL, 33136, USA
| | - Shai S Shemesh
- Department of Orthopaedics, University of Miami Miller School of Medicine, 1400 NW 12th Ave, East Bldg, Ste 2, Miami, FL, 33136, USA
| | - Juan Pretell-Mazzini
- Department of Orthopaedics, University of Miami Miller School of Medicine, 1400 NW 12th Ave, East Bldg, Ste 2, Miami, FL, 33136, USA
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Younan Y, Uriell M, Carpenter W, Umpierrez M, Kakarala A, Jose J, Robertson DD, Subhawong TK, Singer AD. Anatomic Relationship and Imaging Relevance of the Perforating Branches of the Peroneal Vessels to the Anterior Talofibular Ligament. J Emerg Med 2017; 52:707-714. [PMID: 28131608 DOI: 10.1016/j.jemermed.2016.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 12/05/2016] [Accepted: 12/19/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Patients frequently present to the emergency department after ankle injuries, and the anterior talofibular ligament (ATFL) is commonly damaged. Musculoskeletal ultrasound (US) can help to make a rapid diagnosis. There is a paucity of literature describing techniques to image the ATFL with US, and the complex ankle anatomy and potential pitfalls make imaging challenging. OBJECTIVE Our aim was to estimate prevalence of perforating branches (PBs) of the peroneal vessels and determine their most frequent position relative to the ATFL. If these vessels are located in a predictable position at the level of the ATFL, they may serve as a sonographic landmark for the correct imaging plane. METHODS Magnetic resonance imaging (MRI) scans of 105 ankles were reviewed to determine the PB prevalence and location at the ATFL. Inter-observer agreement was determined. Additionally, 16 ankles from 8 asymptomatic subjects were scanned using a high-frequency linear transducer and PB prevalence and location were noted. RESULTS By MRI, PBs were detected in 85% of the ankles and 93% of ankles after consensus. In 73% of cases with agreed PB visualization, vessels assumed a medial position with respect to the ATFL. By US, PBs could be seen in 100% of cases, with the arterial PB seen in 81% of cases and assuming a medial position in 88%. CONCLUSIONS PBs are often present, have a predictable course, and may be useful to help optimize US probe positioning when assessing the ATFL.
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Affiliation(s)
- Yara Younan
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Matthew Uriell
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Walter Carpenter
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Monica Umpierrez
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Aparna Kakarala
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Jean Jose
- Department of Radiology, University of Miami, Miami, Florida
| | - Douglas D Robertson
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Ty K Subhawong
- Department of Radiology, University of Miami, Miami, Florida
| | - Adam Daniel Singer
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
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Klein JS, Jose J, Baraga MG, Subhawong TK. Baseline Cartilage Thickness and Meniscus Extrusion Predict Longitudinal Cartilage Loss by Quantitative Magnetic Resonance Imaging: Data From the Osteoarthritis Initiative. J Comput Assist Tomogr 2017; 40:979-984. [PMID: 27454790 PMCID: PMC5110362 DOI: 10.1097/rct.0000000000000464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to assess how meniscus damage and baseline cartilage thickness influence the rate of cartilage loss and knee pain. METHODS Of 4796 participants in the Osteoarthritis Initiative, 86 had baseline and 48-month follow-up quantitative magnetic resonance imaging data for medial compartment cartilage thickness. Baseline meniscus pathology was scored by a musculoskeletal radiologist using Whole-Organ Magnetic Resonance Imaging Score. Findings were correlated with 72-month Knee injury and Osteoarthritis Outcome Score. RESULTS Univariate analysis showed cartilage change was not influenced by demographic variables. Multivariable regression revealed that initial cartilage thickness (-1.07 mm at 48 months for every 1 mm decrease at baseline, P < 0.001) and meniscus extrusion (-0.33 mm if present at baseline, P < 0.001) were the strongest predictors of medial compartment cartilage thickness at 48 months. Knee injury and Osteoarthritis Outcome Score pain scores did not correlate with cartilage loss. CONCLUSIONS Baseline cartilage thickness and meniscus extrusion are important and independent predictors for accelerated cartilage loss. However, the degree of cartilage loss did not correlate with midterm change in clinical outcome scores.
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Affiliation(s)
- Jason S. Klein
- Department of Orthopaedic Surgery, Sports Medicine Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1400 NW 12th Avenue, Miami, FL 33136, USA
| | - Jean Jose
- Department of Radiology, Musculoskeletal Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave., Miami, FL 33136, USA
| | - Michael G. Baraga
- Department of Orthopaedic Surgery, Sports Medicine Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1400 NW 12th Avenue, Miami, FL 33136, USA
| | - Ty K. Subhawong
- Department of Radiology, Musculoskeletal Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave., Miami, FL 33136, USA
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25
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Tresley J, Wodicka R, Rosenberg A, Pitcher JD, Subhawong TK. Rare Dual Lesion: Extraskeletal Osteosarcoma Developing Within a Simple Lipoma. Am J Orthop (Belle Mead NJ) 2017; 46:E200-E206. [PMID: 28666052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Extraosseous osteosarcoma is a rare malignancy, but simple lipomas are common. This article is the first report of a case of radiation-induced extraosseous osteosarcoma that developed within a simple lipoma in a 72-year-old woman. We correlate the magnetic resonance imaging, computed tomography, positron emission tomography, and plain radiographic findings. The patient, treated with systemic therapy and wide surgical resection of the neoplasm, remained clinically free of disease during the first 22 months of follow-up.
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Sheth PJ, Del Moral S, Wilky BA, Trent JC, Cohen J, Rosenberg AE, Temple HT, Subhawong TK. Desmoid fibromatosis: MRI features of response to systemic therapy. Skeletal Radiol 2016; 45:1365-73. [PMID: 27502790 DOI: 10.1007/s00256-016-2439-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 07/08/2016] [Accepted: 07/11/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Imaging criteria for measuring the response of desmoid fibromatosis to systemic therapy are not well established. We evaluated a series of patients with desmoids who underwent systemic therapy to document magnetic resonance imaging (MRI) features associated with a positive clinical response. MATERIALS AND METHODS This Institutional Review Board-approved retrospective study included 23 patients (mean age 40.5) with 29 extra-abdominal tumors. Therapeutic regimens included cytotoxic chemotherapy (n = 19), targeted therapy (n = 3), and nonsteroid anti-inflammatory drugs (NSAIDS; n = 1). Clinical effects were categorized as progressive disease, stable, or partial response. Maximum tumor dimension (Dmax), approximate tumor volume (VTumor), and quantitative tumor T2 hyperintensity and contrast enhancement (relative to muscle) for pre- and post-treatment MRIs were compared. RESULTS Three lesions progressed, 5 lesions were stable, whereas 21 showed a clinical response. Dmax decreased more in responders (mean -11.0 %) than in stable/progressive lesions (mean -3.6 and 0 % respectively, p = 0.28, ANOVA); by Response Evaluation Criteria in Solid Tumors (RECIST 1.1) 27 out of 29 lesions were "stable," including the 3 progressive lesions. In responders, VTumor change averaged -29.4 %, but -19.2 % and +32.5 % in stable and progressive lesions respectively (p = 0.002, ANOVA); by 3D criteria 14 out of 29 lesions showed a partial response. T2 hyperintensity decreased by 50-54 % in partial response/stable disease, but only by 10 % in progressive lesions (p = 0.049, t test). Changes in contrast enhancement ranged from -23 % to 0 %, but were not statistically significant among response groups (p = 0.37). Change in T2 hyperintensity showed a positive correlation with volumetric change (r = 0.40). CONCLUSION Decreases in volume and T2 hyperintensity reflect the positive response of desmoid fibromatosis to systemic therapy; RECIST 1.1 criteria are not sensitive to clinically determined tumor response.
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Affiliation(s)
- Pooja J Sheth
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Avenue, JMH WW 279, Miami, FL, 33136, USA
| | - Spencer Del Moral
- Division of Hematology/Oncology, Department of Medicine, University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, 33136, USA
| | - Breelyn A Wilky
- Division of Hematology/Oncology, Department of Medicine, University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, 33136, USA
| | - Jonathan C Trent
- Division of Hematology/Oncology, Department of Medicine, University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, 33136, USA
| | - Jonathan Cohen
- Oncology and Radiation Associates, 1321 NW 14th Street, Suite 207, Miami, FL, 33125, USA
| | - Andrew E Rosenberg
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - H Thomas Temple
- Center for Orthopedic Innovations, 3659 S. Miami Avenue, Suite 4008, Miami, FL, 33133, USA
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Avenue, JMH WW 279, Miami, FL, 33136, USA.
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Rizer M, Singer AD, Edgar M, Jose J, Subhawong TK. The histological variants of liposarcoma: predictive MRI findings with prognostic implications, management, follow-up, and differential diagnosis. Skeletal Radiol 2016; 45:1193-204. [PMID: 27209201 DOI: 10.1007/s00256-016-2409-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 05/01/2016] [Accepted: 05/05/2016] [Indexed: 02/07/2023]
Abstract
Liposarcoma is the single most common soft tissue sarcoma accounting for up to 35 % of sarcomas. It represents a histologically diverse group of soft tissue tumors that demonstrate a wide range of imaging appearances with varied behavior patterns. Correspondingly, more aggressive histological subtypes often require management that includes a combination of surgery, chemotherapy, and radiation therapy. Distinguishing among liposarcoma subtypes has important therapeutic and prognostic implications. In this manuscript, we review the liposarcoma subtypes and their histologic and MRI findings, prognostic implications, and differential diagnostic considerations.
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Affiliation(s)
- Magda Rizer
- Department of Radiology, Mount Sinai Medical Center, Miami Beach, FL, USA.
| | - Adam D Singer
- Department of Radiology and Imaging Sciences, Section of Musculoskeletal Imaging, Emory Healthcare, Atlanta, GA, USA
| | - Mark Edgar
- Bone and Soft Tissue Pathology, Department of Pathology, Emory Healthcare, Atlanta, GA, USA
| | - Jean Jose
- Section of Musculoskeletal Imaging, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Ty K Subhawong
- Section of Musculoskeletal Imaging, Miller School of Medicine, University of Miami, Miami, FL, USA
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Tresley J, Subhawong TK, Singer AD, Clifford PD. Incidence of tendon entrapment and dislocation with calcaneus and pilon fractures on CT examination. Skeletal Radiol 2016; 45:977-88. [PMID: 27061188 DOI: 10.1007/s00256-016-2380-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 02/21/2016] [Accepted: 03/21/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the association between tibial pilon and calcaneal fracture classification and tendon entrapment or dislocation. MATERIALS AND METHODS After institutional review board approval, we retrospectively reviewed consecutive CT scans with calcaneal or pilon fractures from 5 years at a level 1 trauma center. We categorized calcaneal fractures according to the Sanders classification, and pilon fractures according to the Ruedi and Allgower and the Arbeitsgemeinschaft für Osteosynthesefragen-Orthopaedic Trauma Association (AO-OTA) classifications. Ankle tendons were assessed for dislocation or entrapment. Fisher's exact test was used for statistical analysis with significance at p < 0.05. RESULTS A total of 312 fractures (91 pilon only, 193 calcaneal only, and 14 ankles with ipsilateral pilon and calcaneal fractures) were identified in 273 patients. Twenty-two pilon, 42 calcaneal, and nine combination fractures were associated with 99 occurrences of tendon entrapment or superior peroneal retinacular injury. Such findings were associated with multiple fractures (p = 0.002). Multifragmentary pilon fractures were associated with posterior tibial and flexor digitorum longus tendon entrapment (p < 0.0001 and p = 0.0003 for Ruedi/Allgower and AO-OTA, respectively), and multifragmentary Sanders type 3 or 4 calcaneal fractures were associated with superior peroneal retinacular injury (p = 0.0473) compared to simple fracture patterns. Thirty-nine percent of tendon entrapments or retinacular injuries were prospectively identified, 85 % by musculoskeletal radiologists (p < 0.0001). CONCLUSIONS Approximately 25 % of calcaneal and pilon fractures were retrospectively identified to contain posteromedial tendon entrapment or superior peroneal retinacular injury. Radiologists should meticulously search for such injuries, particularly when analyzing multifragmentary and multiple fractures.
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Affiliation(s)
- Jonathan Tresley
- Department of Diagnostic Radiology, Jackson Memorial Hospital, West Wing 279, 1611 NW 12th Avenue, Miami, FL, 33136, USA.
- Department of Radiology, University of Wisconsin-Madison, G3/338, 600 Highland Avenue, Madison, WI, 53792, USA.
| | - Ty K Subhawong
- Department of Diagnostic Radiology, Jackson Memorial Hospital, West Wing 279, 1611 NW 12th Avenue, Miami, FL, 33136, USA
| | - Adam D Singer
- Department of Diagnostic Radiology, Jackson Memorial Hospital, West Wing 279, 1611 NW 12th Avenue, Miami, FL, 33136, USA
| | - Paul D Clifford
- Department of Diagnostic Radiology, Jackson Memorial Hospital, West Wing 279, 1611 NW 12th Avenue, Miami, FL, 33136, USA
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Abstract
Plasmacytomas are rare tumors, which arise from the monoclonal proliferation of malignant plasma cells. They may affect either the bony skeleton or rarely the soft tissues, the latter being referred to as extramedullary or extraosseous. We report a case of an extramedullary plasmacytoma that presented as a soft tissue mass involving the muscles of the left leg, in a patient who was previously treated for multiple myeloma. We describe the MR Imaging characteristics of the tumor and highlight the usefulness of diffusion-weighted imaging with apparent diffusion coefficient mapping.
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Affiliation(s)
- Amrutha Ramachandran
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alero F Inyang
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
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Singer AD, Pattany PM, Fayad LM, Tresley J, Subhawong TK. Volumetric segmentation of ADC maps and utility of standard deviation as measure of tumor heterogeneity in soft tissue tumors. Clin Imaging 2015; 40:386-91. [PMID: 27133673 DOI: 10.1016/j.clinimag.2015.11.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/31/2015] [Accepted: 11/05/2015] [Indexed: 12/26/2022]
Abstract
PURPOSE Determine interobserver concordance of semiautomated three-dimensional volumetric and two-dimensional manual measurements of apparent diffusion coefficient (ADC) values in soft tissue masses (STMs) and explore standard deviation (SD) as a measure of tumor ADC heterogeneity. RESULTS Concordance correlation coefficients for mean ADC increased with more extensive sampling. Agreement on the SD of tumor ADC values was better for large regions of interest and multislice methods. Correlation between mean and SD ADC was low, suggesting that these parameters are relatively independent. CONCLUSION Mean ADC of STMs can be determined by volumetric quantification with high interobserver agreement. STM heterogeneity merits further investigation as a potential imaging biomarker that complements other functional magnetic resonance imaging parameters.
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Affiliation(s)
- Adam D Singer
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA.
| | | | - Laura M Fayad
- Department of Radiology, Johns Hopkins University, Baltimore, MD
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Abstract
Diffusion-weighted (DW) imaging is a functional magnetic resonance (MR) imaging technique that can readily be incorporated into a routine non-contrast material-enhanced MR imaging protocol with little additional scanning time. DW imaging is based on changes in the Brownian motion of water molecules caused by tissue microstructure. The apparent diffusion coefficient (ADC) is a quantitative measure of Brownian movement: Low ADC values typically reflect highly cellular microenvironments in which diffusion is restricted by the presence of cell membranes, whereas acellular regions allow free diffusion and result in elevated ADC values. Thus, with ADC mapping, one may derive useful quantitative information regarding the cellularity of a musculoskeletal lesion using a nonenhanced technique. The role of localized DW imaging in differentiating malignant from benign osseous and soft-tissue lesions is still evolving; when carefully applied, however, this modality has proved helpful in a subset of tumor types, such as nonmyxoid soft-tissue tumors. Studies of the use of DW imaging in assessing the treatment response of both osseous and soft-tissue tumors have shown that higher ADC values correlate with better response to cytotoxic therapy. Successful application of DW imaging in the evaluation of musculoskeletal lesions requires familiarity with potential diagnostic pitfalls that stem from technical artifacts and confounding factors unrelated to lesion cellularity. Further investigation is needed to evaluate the impact of DW imaging-ADC mapping on management and outcome in patients with musculoskeletal lesions.
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Affiliation(s)
- Ty K Subhawong
- From the Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave, Miami, FL 33136 (T.K.S.); and Sidney Kimmel Comprehensive Cancer Center (M.A.J., L.M.F.), Russell H. Morgan Department of Radiology and Radiological Science (M.A.J., L.M.F.), and Department of Orthopaedic Surgery (L.M.F.), Johns Hopkins Medical Institutions, Baltimore, Md
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Chhabra A, Belzberg AJ, Rosson GD, Thawait GK, Chalian M, Farahani SJ, Shores JT, Deune G, Hashemi S, Thawait SK, Subhawong TK, Carrino JA. Impact of high resolution 3 tesla MR neurography (MRN) on diagnostic thinking and therapeutic patient management. Eur Radiol 2015; 26:1235-44. [DOI: 10.1007/s00330-015-3958-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 07/26/2015] [Accepted: 07/30/2015] [Indexed: 01/05/2023]
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Zeidenberg J, Burks SS, Jose J, Subhawong TK, Levi AD. The utility of ultrasound in the assessment of traumatic peripheral nerve lesions: report of 4 cases. Neurosurg Focus 2015; 39:E3. [DOI: 10.3171/2015.6.focus15214] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ultrasound technology continues to improve with better image resolution and availability. Its use in evaluating peripheral nerve lesions is increasing. The current review focuses on the utility of ultrasound in traumatic injuries. In this report, the authors present 4 illustrative cases in which high-resolution ultrasound dramatically enhanced the anatomical understanding and surgical planning of traumatic peripheral nerve lesions. Cases include a lacerating injury of the sciatic nerve at the popliteal fossa, a femoral nerve injury from a pseudoaneurysm, an ulnar nerve neuroma after attempted repair with a conduit, and, finally, a spinal accessory nerve injury after biopsy of a supraclavicular fossa lesion. Preoperative ultrasound images and intraoperative pictures are presented with a focus on how ultrasound aided with surgical decision making. These cases are set into context with a review of the literature on peripheral nerve ultrasound and a comparison between ultrasound and MRI modalities.
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Affiliation(s)
- Joshua Zeidenberg
- 1Department of Radiology, University of Miami/Jackson Memorial Hospital; and
| | - S. Shelby Burks
- 2Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
| | - Jean Jose
- 1Department of Radiology, University of Miami/Jackson Memorial Hospital; and
| | - Ty K. Subhawong
- 1Department of Radiology, University of Miami/Jackson Memorial Hospital; and
| | - Allan D. Levi
- 2Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
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Ahlawat S, Khandheria P, Del Grande F, Morelli J, Subhawong TK, Demehri S, Fayad LM. Interobserver variability of selective region-of-interest measurement protocols for quantitative diffusion weighted imaging in soft tissue masses: Comparison with whole tumor volume measurements. J Magn Reson Imaging 2015; 43:446-54. [PMID: 26174705 DOI: 10.1002/jmri.24994] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 06/23/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND To assess the interobserver reliability of three selective region-of-interest (ROI) measurement protocols for apparent diffusion coefficient (ADC) quantifications in soft tissue masses (STMs) compared with whole tumor volume (WTV) ADC measurements. METHODS Institutional review board approval was obtained and informed consent was waived. Three observers independently measured minimum and mean ADCs of 73 benign and malignant musculoskeletal STMs using three selective methods (single-slice [SS], predefined three slices [PD], observer-based [OB]) and WTV measurements at 3.0 Tesla. Minimum and mean ADC values derived from each method were compared with WTV measurements, and inter-reader variation was assessed using the intraclass correlation coefficient (ICC). The time required for each method of ADC measurement was recorded. RESULTS For the SS, PD, OB, and WTV methods, minimum ADC values ((×10(-3) mm2 /s)) were 0.97, 0.78, 0.73, and 0.67, respectively, and mean ADC values ((×10(-3) mm2 /s)) were 1.49, 1.49, 1.51, and 1.49, respectively. Interobserver agreement was good to excellent for the minimum and mean ADC values for the three readers using the SS, PD, OB, and WTV (ICC range 0.78-0.90). The SS, PD and OB methods required the least amount of measurement time (14 ± 5, 40 ± 17, and 38 ± 15 s, respectively) while the reference WTV method required the longest measurement time (111 ± 54 s) (P < 0.01). CONCLUSION While all selective and WTV measurements offer good to excellent interobserver agreement, the selective OB method of ADC measurement results in the closest values to WTV measurements and requires significantly less measurement time than that required for the WTV method.
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Affiliation(s)
- Shivani Ahlawat
- The Johns Hopkins Medical Institutions, The Russell H. Morgan Department of Radiology & Radiological Science, Baltimore, Maryland, USA
| | - Paras Khandheria
- The Johns Hopkins Medical Institutions, The Russell H. Morgan Department of Radiology & Radiological Science, Baltimore, Maryland, USA
| | - Filippo Del Grande
- The Johns Hopkins Medical Institutions, The Russell H. Morgan Department of Radiology & Radiological Science, Baltimore, Maryland, USA.,Department of Radiology, Regional Hospital, Lugano, Switzerland
| | - John Morelli
- Tulsa Radiology Associates, Tulsa, Oklahoma, USA
| | - Ty K Subhawong
- Department of Radiology (R-109), University of Miami, Miami, Florida, USA
| | - Shadpour Demehri
- The Johns Hopkins Medical Institutions, The Russell H. Morgan Department of Radiology & Radiological Science, Baltimore, Maryland, USA
| | - Laura M Fayad
- The Johns Hopkins Medical Institutions, The Russell H. Morgan Department of Radiology & Radiological Science, Baltimore, Maryland, USA
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Subhawong TK, Jacobs MA, Fayad LM. Correction: Notice of Redundant Publication. Radiographics 2015; 35:652. [DOI: 10.1148/rg.352144016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
The tarsal navicular is a bone within the midfoot that plays a critical role in maintaining the arch of the foot. This bone is clinically relevant because it may be affected by a wide array of pathologies. Our approach includes a detailed description of the imaging characteristics and disorders affecting the tarsal navicular. Organization includes (a) normal imaging, (b) accessory ossicles, (c) coalition, (d) fractures, (e) Kohler's disease, (f) osteonecrosis, (g) osteochondral lesions, (h) arthropathies, and (i) tumors. The purpose of this article is to discuss normal variants and pathological processes that can affect the tarsal navicular, with emphasis on the often-overlooked imaging findings.
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Affiliation(s)
- Heidi L Tuthill
- University of Miami Miller School of Medicine/Jackson Health System, Miami, Florida (HLT, ERF, AMS, PDC, TKS, JJ)
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Fayad LM, Wang X, Blakeley JO, Durand DJ, Jacobs MA, Demehri S, Subhawong TK, Soldatos T, Barker PB. Characterization of peripheral nerve sheath tumors with 3T proton MR spectroscopy. AJNR Am J Neuroradiol 2013; 35:1035-41. [PMID: 24287094 DOI: 10.3174/ajnr.a3778] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND PURPOSE The characterization of peripheral nerve sheath tumors is challenging. The purpose here was to investigate the diagnostic value of quantitative proton MR spectroscopy at 3T for the characterization of peripheral nerve sheath tumors as benign or malignant, compared with PET. MATERIALS AND METHODS Twenty participants with 24 peripheral nerve sheath tumors underwent MR spectroscopy by use of a point-resolved sequence (TE, 135 ms). Six voxels were placed in 4 histologically proven malignant peripheral nerve sheath tumors and 22 voxels in 20 benign peripheral nerve sheath tumors (9 histologically proven, 11 with documented stability). The presence or absence of a trimethylamine signal was evaluated, the trimethylamine concentration estimated by use of phantom replacement methodology, and the trimethylamine fraction relative to Cr measured. MR spectroscopy results for benign and malignant peripheral nerve sheath tumors were compared by use of a Mann-Whitney test, and concordance or discordance with PET findings was recorded. RESULTS In all malignant tumors and in 9 of 18 benign peripheral nerve sheath tumors, a trimethylamine peak was detected, offering the presence of trimethylamine as a sensitive (100%), but not specific (50%), marker of malignant disease. Trimethylamine concentrations (2.2 ± 2.8 vs 6.6 ± 5.8 institutional units; P < .049) and the trimethylamine fraction (27 ± 42 vs 88 ± 22%; P < .012) were lower in benign than malignant peripheral nerve sheath tumors. A trimethylamine fraction threshold of 50% resulted in 100% sensitivity (95% CI, 58.0%-100%) and 72.2% (95% CI, 59.5%-75%) specificity for distinguishing benign from malignant disease. MR spectroscopy and PET results were concordant in 12 of 16 cases, (2 false-positive results for MR spectroscopy and PET each). CONCLUSIONS Quantitative measurement of trimethylamine concentration by use of MR spectroscopy is feasible in peripheral nerve sheath tumors and shows promise as a method for the differentiation of benign and malignant lesions. Trimethylamine presence within a peripheral nerve sheath tumor is a sensitive marker of malignant disease, but quantitative measurement of trimethylamine content is required to improve specificity.
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Affiliation(s)
- L M Fayad
- From The Russell H. Morgan Department of Radiology and Radiological Science (L.M.F., X.W., D.J.D., S.D., M.A.J., P.B.B.)Orthopedic Surgery (L.M.F.)Oncology (L.M.F., M.A.J.), The Johns Hopkins Hospital Comprehensive Neurofibromatosis Center
| | - X Wang
- From The Russell H. Morgan Department of Radiology and Radiological Science (L.M.F., X.W., D.J.D., S.D., M.A.J., P.B.B.)
| | - J O Blakeley
- Department of Neurology (J.O.B.), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - D J Durand
- From The Russell H. Morgan Department of Radiology and Radiological Science (L.M.F., X.W., D.J.D., S.D., M.A.J., P.B.B.)
| | - M A Jacobs
- From The Russell H. Morgan Department of Radiology and Radiological Science (L.M.F., X.W., D.J.D., S.D., M.A.J., P.B.B.)Oncology (L.M.F., M.A.J.), The Johns Hopkins Hospital Comprehensive Neurofibromatosis Center
| | - S Demehri
- From The Russell H. Morgan Department of Radiology and Radiological Science (L.M.F., X.W., D.J.D., S.D., M.A.J., P.B.B.)
| | - T K Subhawong
- Department of Radiology (T.K.S.), University of Miami Miller School of Medicine, Miami, Florida
| | - T Soldatos
- Research Unit of Radiology and Medical Imaging (T.S.), National and Capodestrian University of Athens, Evgenidion Hospital, Athens, Greece
| | - P B Barker
- From The Russell H. Morgan Department of Radiology and Radiological Science (L.M.F., X.W., D.J.D., S.D., M.A.J., P.B.B.)
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Subhawong TK, Durand DJ, Thawait GK, Jacobs MA, Fayad LM. Characterization of soft tissue masses: can quantitative diffusion weighted imaging reliably distinguish cysts from solid masses? Skeletal Radiol 2013; 42:1583-92. [PMID: 23974467 PMCID: PMC9372881 DOI: 10.1007/s00256-013-1703-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 07/19/2013] [Accepted: 07/25/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the accuracy of quantitative diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping for characterizing soft tissue masses (STMs) as cysts or solid masses. MATERIALS AND METHODS This IRB-approved retrospective study included 36 subjects with 37 STMs imaged by conventional MRI (T1-weighted, T2-weighted, contrast-enhanced T1-weighted sequences) and DWI (b-values 50, 400, 800 s/mm(2)) with ADC mapping. STMs were defined as non-solid cysts by histology or clinical follow-up, and as solid by histology. For each STM, ADC values (range, mean) were recorded by two observers. Differences between ADC values in cysts and solid STMs were compared using Wilcoxon rank-sum and receiver-operating characteristic (ROC) analysis. RESULTS There were higher minimum (1.65 vs 0.68, p = 0.003) and mean (2.31 vs 1.45, p = 0.005) ADC values in cysts than solid STMs respectively. Areas under the ROC for minimum and mean ADC values were 0.82 and 0.81 respectively. Using threshold ADC values of 1.8 (minimum) or 2.5 (mean) yielded a sensitivity of 60 % and 80 % respectively, and a specificity of 100 % for classifying a STM as a cyst; for tumors with high fluid-signal intensity, the performance of these threshold values was maintained. CONCLUSION Diffusion-weighted imaging with ADC mapping provides a non-contrast MRI alternative for the characterization of STMs as cysts or solid masses. Threshold ADC values exist that provide 100 % specificity for differentiating cysts and solid STMs, even for tumors of high fluid-signal intensity on T2-weighted images.
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Affiliation(s)
- Ty K. Subhawong
- Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave, JMH WW 279, Miami, FL 33136, USA
| | - Daniel J. Durand
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 601 N. Wolfe St., Baltimore, MD 21287, USA
| | - Gaurav K. Thawait
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 601 N. Wolfe St., Baltimore, MD 21287, USA
| | - Michael A. Jacobs
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 601 N. Wolfe St., Baltimore, MD 21287, USA
| | - Laura M. Fayad
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 601 N. Wolfe St., Baltimore, MD 21287, USA
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Thawait GK, Subhawong TK, Tatizawa Shiga NY, Fayad LM. "Cystic"-appearing soft tissue masses: what is the role of anatomic, functional, and metabolic MR imaging techniques in their characterization? J Magn Reson Imaging 2013; 39:504-11. [PMID: 24532375 DOI: 10.1002/jmri.24314] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 06/21/2013] [Indexed: 11/05/2022] Open
Abstract
Although conventional MR imaging with contrast-enhanced T1-weighted sequences is of paramount importance for evaluating soft tissue masses, noncontrast MR sequences have emerged that facilitate their characterization. In this article, the utility and pitfalls of conventional MR imaging with T1-weighted, fluid-sensitive, and contrast-enhanced sequences will be discussed, along with that of functional (diffusion weighted imaging) and metabolic (proton MR spectroscopy) non-contrast-enhanced techniques for the purpose of soft tissue mass characterization. In particular, we discuss the application of these techniques to differentiating neoplastic or inflammatory masses that have high fluid content from benign cysts, as this distinction is a common pitfall of conventional sequences.
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Affiliation(s)
- Gaurav K Thawait
- Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, 601 North Wolfe Street, Baltimore, Maryland, USA
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Subhawong AP, Subhawong TK, Vandenbussche CJ, Siddiqui MT, Ali SZ. Lymphoproliferative disorders of the kidney on fine-needle aspiration: cytomorphology and radiographic correlates in 33 cases. Acta Cytol 2013; 57:19-25. [PMID: 23221130 DOI: 10.1159/000342574] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 08/09/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Unless renal lesions present in the setting of widespread lymphoma, biopsy can be indicated to differentiate from metastases, hypovascular renal cell carcinoma, urothelial carcinoma or infection. We review our experience with lymphoproliferative disorders in the kidney diagnosed by fine-needle aspiration (FNA), and focus on clinicopathologic and radiographic features. DESIGN All cases of non-Hodgkin lymphoma diagnosed on renal FNA at 2 academic institutions between 1989 and 2011 were reviewed. Clinical history, radiographic and cytomorphologic features, and follow-up were assessed. RESULTS 33 cases were identified, with 15 primary tumors and 18 recurrences/secondary tumors including 1 acute lymphoblastic lymphoma. The majority were aggressive/high-grade lesions (25/33). 25 cases were substantiated by positive flow cytometry results. Most were detected at follow-up/incidentally. 22 cases showed multiple renal and/or retroperitoneal masses or a significant component of adenopathy; others showed a solitary renal mass. Salient radiologic features included hypodense, infiltrative and ill-defined masses. Cytomorphology showed a monotonous population of large atypical lymphoid cells, often with lymphoglandular bodies. CONCLUSION Cytologic diagnosis of renal lymphoma requires analysis of morphological, clinical and immunophenotypic information. Helpful features for diagnosis include: multiple masses on computed tomography, a monotonous population of abnormal cells in a background of lymphoglandular bodies and immunophenotyping demonstrating light chain restriction.
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Affiliation(s)
- Andrea P Subhawong
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
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41
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Thawait GK, Subhawong TK, Thawait SK, Andreisek G, Belzberg AJ, Eng J, Carrino JA, Chhabra A. Magnetic resonance neurography of median neuropathies proximal to the carpal tunnel. Skeletal Radiol 2012; 41:623-32. [PMID: 22426804 DOI: 10.1007/s00256-012-1380-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 02/13/2012] [Accepted: 02/14/2012] [Indexed: 02/02/2023]
Abstract
This review provides magnetic resonance neurography (MRN) imaging appearances of median neuropathy proximal to the carpal tunnel. Carpal tunnel syndrome (CTS) and its imaging have been extensively described in the literature; however, there is a relative paucity of information on the MR imaging appearances of different pathologies of the median nerve proximal to the carpal tunnel.
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Affiliation(s)
- Gaurav K Thawait
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, MD 21287, USA.
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Thawait SK, Wang K, Subhawong TK, Williams EH, Hashemi SS, Machado AJ, Thawait GK, Soldatos T, Carrino JA, Chhabra A. Peripheral nerve surgery: the role of high-resolution MR neurography. AJNR Am J Neuroradiol 2012; 33:203-10. [PMID: 21527571 DOI: 10.3174/ajnr.a2465] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
High-resolution MRN is becoming increasingly available due to recent technical advancements, including higher magnetic field strengths (eg, 3T), 3D image acquisition, evolution of novel fat-suppression methods, and improved coil design. This review describes the MRN techniques for obtaining high-quality images of the peripheral nerves and their small branches and imaging findings in normal as well as injured nerves with relevant intraoperative correlations. Various microsurgical techniques in peripheral nerves, such as neurolysis, nerve repairs by using nerve grafts, and conduits are discussed, and MRN findings of surgically treated nerves are demonstrated.
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Affiliation(s)
- S K Thawait
- Department of Radiology, Bridgeport Hospital, Yale New Haven Health System, Bridgeport, Connecticut, USA
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Subhawong AP, Subhawong TK, Ali SZ. Hairy cell leukemia presenting as a peripancreatic mass: cytomorphology and radiographic correlates. Acta Cytol 2012; 56:463-6. [PMID: 22846478 DOI: 10.1159/000335731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 12/13/2011] [Indexed: 11/19/2022]
Abstract
Hairy cell leukemia (HCL) usually presents with peripheral cytopenias, diffuse marrow infiltration, and splenomegaly. This chronic lymphoproliferative disorder is not typically associated with lymphadenopathy or mass lesions. We report a case of HCL first treated by splenectomy, followed by several years of interferon therapy. Twenty-five years later, the patient presented with weight loss, fatigue, and a large PET-avid mass surrounding the head of the pancreas. Fine-needle aspiration was pursued to investigate the unusual and infiltrative appearance of the lesion, which was suggestive of another primary malignancy. Cytology smears showed discohesive lymphoid cells with round nuclei and delicate cytoplasmic projections. Flow cytometry confirmed the presence of a clonal B-cell population with bright expression of CD20 as well as CD25 and CD103, diagnostic of HCL. This is the first report of HCL presenting as a peripancreatic mass. The importance of correlation with radiology and clinical history is emphasized when evaluating such lesions.
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MESH Headings
- Aged, 80 and over
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antineoplastic Agents/therapeutic use
- Biopsy, Fine-Needle
- Humans
- Leukemia, Hairy Cell/diagnostic imaging
- Leukemia, Hairy Cell/pathology
- Male
- Neoplasm Recurrence, Local/diagnostic imaging
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/pathology
- Neoplasms, Multiple Primary/pathology
- Pancreas/pathology
- Pentostatin/therapeutic use
- Prostatic Neoplasms/pathology
- Radiography
- Rituximab
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Affiliation(s)
- A P Subhawong
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Subhawong AP, Subhawong TK, Ali SZ. Large cell transformation of mycosis fungoides on fine needle aspiration: an unusual case mimicking classical Hodgkin lymphoma. Acta Cytol 2012; 56:321-4. [PMID: 22555537 DOI: 10.1159/000335570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 12/05/2011] [Indexed: 11/19/2022]
Abstract
Mycosis fungoides (MF), the most common type of primary cutaneous T-cell lymphoma, undergoes large cell transformation in only a minority of cases that present in patch stage. We describe a 52-year-old patient with a history of unilesional patch stage MF treated with localized radiotherapy. He had disease recurrence 5 years later and began psoralen plus ultraviolet A treatment with good response. After inguinal lymphadenopathy was detected on physical examination, a follow-up PET scan showed a fluorodeoxyglucose-avid inguinal node, which was evaluated by fine needle aspiration. Cytomorphology showed numerous Reed-Sternberg-like cells, highly suspicious for Hodgkin lymphoma. Histologic sections revealed isolated sinusoidal involvement by pleomorphic CD30-positive tumor cells, diagnostic of large cell transformation of MF in light of clinical history. The cells were also positive for CD15 and CD4. This case emphasizes morphologic features of an entity with limited description in the cytology literature and adds to the growing number of reported CD15-positive T-cell lymphomas.
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Affiliation(s)
- A P Subhawong
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
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Subhawong TK, Wang KC, Thawait SK, Williams EH, Hashemi SS, Machado AJ, Carrino JA, Chhabra A. High resolution imaging of tunnels by magnetic resonance neurography. Skeletal Radiol 2012; 41:15-31. [PMID: 21479520 PMCID: PMC3158963 DOI: 10.1007/s00256-011-1143-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 02/24/2011] [Accepted: 02/25/2011] [Indexed: 02/02/2023]
Abstract
Peripheral nerves often traverse confined fibro-osseous and fibro-muscular tunnels in the extremities, where they are particularly vulnerable to entrapment and compressive neuropathy. This gives rise to various tunnel syndromes, characterized by distinct patterns of muscular weakness and sensory deficits. This article focuses on several upper and lower extremity tunnels, in which direct visualization of the normal and abnormal nerve in question is possible with high resolution 3T MR neurography (MRN). MRN can also serve as a useful adjunct to clinical and electrophysiologic exams by discriminating adhesive lesions (perineural scar) from compressive lesions (such as tumor, ganglion, hypertrophic callous, or anomalous muscles) responsible for symptoms, thereby guiding appropriate treatment.
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Affiliation(s)
- Ty K Subhawong
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 601 N. Caroline Street, Room 4214, Baltimore, MD 21287, USA.
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Murphy RJ, Subhawong TK, Chhabra A, Carrino JA, Armand M, Hungerford M. A quantitative method to assess focal acetabular overcoverage resulting from pincer deformity using CT data. Clin Orthop Relat Res 2011; 469:2846-54. [PMID: 21748515 PMCID: PMC3171557 DOI: 10.1007/s11999-011-1958-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 06/17/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Current assessment techniques for focal acetabular overcoverage are neither consistent nor quantitatively accurate. QUESTIONS/PURPOSES We propose: (1) a method to precisely quantify the amount of focal acetabular overcoverage in a patient's pincer deformity based on CT data; (2) to evaluate the consistency of this method; and (3) to compare the method with conventional radiographic assessments. METHODS We developed a method to assess focal acetabular overcoverage using points selected from CT scans along the acetabular rim after realigning the pelvis into a neutral position. Using four resampled and segmented pelvic CT scans of cadaveric specimens with virtually induced impingement, two observers independently tested the algorithm's consistency. Our algorithm assessed the amount of focal acetabular overcoverage using CT data and projected data from reconstructed radiographs. RESULTS (1) We successfully showed the feasibility of the software to produce consistent, quantitative measurements. (2) Testing showed the average difference between observers in aligning the pelvis was 0.42°, indicative of a consistent approach. (3) Differences between measurements on three-dimensional (3-D) CT and simulated radiographs were significant. CONCLUSIONS The proposed method represents a new avenue in consistently quantifying focal acetabular overcoverage using CT models while correcting for pelvic tilt and rotation. Our analysis confirms AP hip radiograph simulations overestimate the amount of overhanging acetabular rim in a pincer deformity. CLINICAL RELEVANCE This technique has potential to improve preoperative diagnostic accuracy and enhance surgical planning for correction of a pincer deformity resulting from focal acetabular overcoverage.
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Affiliation(s)
- Ryan J Murphy
- Milton S Eisenhower Research Center, The Johns Hopkins University Applied Physics Laboratory, 11100 Johns Hopkins Road, 21 N109, Laurel, MD 20723, USA.
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Chhabra A, Subhawong TK, Bizzell C, Flammang A, Soldatos T. 3T MR neurography using three-dimensional diffusion-weighted PSIF: technical issues and advantages. Skeletal Radiol 2011; 40:1355-60. [PMID: 21494905 DOI: 10.1007/s00256-011-1162-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Revised: 03/20/2011] [Accepted: 03/21/2011] [Indexed: 02/02/2023]
Abstract
Three-dimensional (3D) diffusion-weighted reversed fast imaging with steady state precession (3D DW-PSIF) MR sequence has the potential to create nerve-specific images. The authors describe the technical issues and their initial experience with this imaging technique employed for peripheral MR neurography.
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Affiliation(s)
- Avneesh Chhabra
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 601 North Caroline Street, Room 4214, Baltimore, MD 21287, USA.
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Chhabra A, Soldatos T, Subhawong TK, Machado AJ, Thawait SK, Wang KC, Padua A, Flammang AJ, Williams EH, Carrino JA. The application of three-dimensional diffusion-weighted PSIF technique in peripheral nerve imaging of the distal extremities. J Magn Reson Imaging 2011; 34:962-7. [PMID: 21769979 DOI: 10.1002/jmri.22684] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 05/23/2011] [Indexed: 11/08/2022] Open
Affiliation(s)
- Avneesh Chhabra
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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Abstract
Injuries of the deltoid ligament of the ankle are increasingly recognized with the widespread use of magnetic resonance (MR) imaging. The use of higher magnetic field strengths requires familiarity with the anatomic substructure of the deltoid ligament to better localize and characterize pathologic findings. Specifically, improved image resolution allows components of the superficial (tibiocalcaneal, tibionavicular, posterior superficial tibiotalar, and tibiospring ligaments) and deep (anterior tibiotalar and posterior deep tibiotalar ligaments) portions of the ligament to be evaluated separately. Awareness of the deltoid ligament substructure and associated injury patterns can guide the radiologist in defining underlying mechanical derangement, such as that seen in various impingement disorders. In this review article, the MR imaging technique for the deltoid ligament is summarized, and the normal and abnormal MR imaging appearances of various components of the deltoid ligament and associated impingement syndromes are presented.
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Affiliation(s)
- Avneesh Chhabra
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, 601 N Caroline St, Baltimore, MD 21287, USA
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50
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Affiliation(s)
- Ty K Subhawong
- Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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