Soft Tissue Components Research Articles

Correlation of the MRI findings with clinical assessment, intraoperative and biopsy findings: Osseous spine tumors

The annual incidence of primary spine neoplasms has been estimated at 2.5 per 1,00,000 per year.' The careful study of plain roentgenograms of spine is the first step for proper evaluation of diseases of the osseous spine. Not only the bone and joint structures of the vertebral column are important from the neurologic standpoint but also the contour and calibre of the vertebral canal and foramina of exit of the spinal nerve roots. In the case of a patient with clinical suspicion of osseous spine tumor, a complete clinical history with special reference to neurological symptoms was taken, followed by general physical examination and detailed central nervous system examination. Other systems were also examined and findings were noted. Next, the procedure for MRI was explained to the patient and consent was taken. In this study, 7 cases showed paraspinal soft tissue component. Contrast was given in all the cases. The paraspinal soft tissue component enhanced well on post contrast in all the cases.

Diffuse Strong Membrane Expression of MIC2 (CD99) in Anaplastic Large Cell Lymphoma: A Diagnostic Challenge

The MIC2 [Cluster of Differentiation 99 (CD99)] has been widely used in making the diagnosis of Ewing’s sarcoma and diffuse strong membrane expression is the characteristic finding. The CD99 is a sensitive marker of Ewing’s sarcoma, but not specific. Studies have shown expression of CD99 in a wide variety of neoplasms which include epithelial, mesenchymal and haematopoietic neoplasms. In these tumours, the positivity of CD99 is described as variable with focal/patchy, irregular, membrane/cytoplasmic staining. Among the haematopoetic neoplasms, diffuse strong positivity of CD99 is seen in blasts which include T-lymphoblasts, B-lymphoblasts and myeloblasts. Recent studies have demonstrated positive staining of CD99 in mature lymphomas where the pattern of expression is heterogenous and highly variable. Herein, authors report the case of a 42-year-old male patient with expansile destructive lesion in right scapula with large soft tissue component. With clinical diagnosis of sarcoma, biopsy was taken which showed large atypical cells arranged diffusely, focally around vessels and in vague rosettoid pattern. In the initial immunopanel, neoplastic cells showed diffuse strong membrane expression of CD99 and were negative for cytokeratin, synaptophysin, chromogranin, desmin and S100. On further examination, the neoplastic cells showed focal weak to moderate positivity for CD45, diffuse strong positivity for CD30 and strong positivity for Anaplastic Lymphoma Kinase (ALK). Diagnosis of ALK positive Anaplastic Large Cell Lymphoma (ALCL) was given. The awareness of diffuse strong membrane pattern of staining of CD99 in ALCL will help to avoid misdiagnosis especially in cases with atypical clinical presentations.

Radiation diagnostics of peripheral primitive
 neuroectodermal tumors (PNET)
 in children at the Scientific Center
 of Pediatrics and Pediatric Surgery
 (Almaty, Kazakhstan)

Relevance: Peripheral primitive neuroectodermal tumor (primitive neuroectodermal tumor – PNET) belongs to the group
 of malignant tumors that develop from migrating embryonic neural crest cells. PNET includes several nosological forms: Askin’s
 tumor, esthesioneuroblastoma, the very peripheral primitive neuroectodermal tumor, and Ewing’s sarcoma. PNET accounts for
 3–9% of all soft tissue tumors and 19% of all soft tissue sarcomas in children. In Europe and the US, PNETs account for 3.4 cases
 per year per 1 million children below 15 years; in Kazakhstan – 0.6-1.2 cases per 1 million child population. Rapid tumor growth,
 malignancy, and early metastasis to other organs and systems predetermine the PNET’s specific role in oncology.
 The purpose of the study was to improve the quality and availability of early sarcoma diagnostics in children at medical
 institutions of the general medical network.
 Results: 35 cases of peripheral PNET in children were analyzed. The age of the patients was 1.5 to 17 years, the average age –
 9.3 years. Boys were 1.3 times more than girls. One patient (3.6%) had extra-skeletal tumor localization. Children with stage IIB
 prevailed – 46.4% of cases (13 children).
 Radiographical differentiation between Ewing’s sarcoma and primary chronic or “healed” (antibiotic) acute hematogenous
 osteomyelitis in the initial phase of the process is almost impossible before the extraosseous soft tissue component is formed.
 The bone damage process is more often localized in the bone diaphysis and subsequently spreads to its metaphyses.
 Conclusion: PNET is more likely to come from the chest wall, so it is advisable to start the X-ray examination from the chest.
 In terms of radiation semiotics, PNET is similar to Ewing’s sarcoma and Askin’s tumor; therefore, an additional immunohistochemical study of the tumor tissue is required. An important indirect diagnostic criterion in Ewing’s sarcoma is the predominance of the soft tissue component over the bone manifestations. Extended CT and MRI studies with contrast enhancement
 (chest, abdominal cavity, pelvis, and the primary lesion area) and skeletal scintigraphy are required to clarify the extent of
 changes, stage the tumor accurately, and assess the tumor dynamics after treatment. The above conclusions generally confirm
 the available literature data.

Radiation diagnosis of peripheral
 primitive neuroectodermal tumors
 (PNET) in children under
 the conditions of the scientific center of
 pediatrics and pediatric surgery
 (Almaty, Kazakhstan)

Relevance: Peripheral primitive neuroectodermal tumor (PNET) belongs to the group of malignant tumors that
 develop from migrating embryonic neural crest cells. PNET
 includes several nosological forms: Askin’s tumor, esthesioneuroblastoma, the very peripheral primitive neuroectodermal tumor, and Ewing’s sarcoma [1]. PNET accounts
 for 3–9% of all soft tissue tumors and 19% of all soft tissue
 sarcomas in children [2, 3]. In Europe and the US, PNETs account for 3.4 cases per year per 1 million children below 15
 years; in Kazakhstan – 0.6-1.2 cases per 1 million child population. Rapid tumor growth, malignancy, and early metastasis to other organs and systems predetermine the PNET’s
 specific role in oncology [4].
 The purpose was to improve the quality and availability of early sarcoma diagnostics in children in medical institutions of the general medical network.
 Results: 35 cases of peripheral PNET in children were analyzed. The age of the patients was 1.5 to 17 years, the average age – 9.3 years. Boys were 1.3 times more than girls. One
 patient (3.6%) had extra-skeletal tumor localization. Children with stage IIB prevailed – 46.4% of cases (13 children).
 Radiographical differentiation between Ewing’s sarcoma and primary chronic or “healed” (antibiotic) acute
 hematogenous osteomyelitis in the initial phase of the process is almost impossible before the extraosseous soft tissue
 component is formed. The bone damage process is more
 often localized in the bone diaphysis and subsequently
 spreads to its metaphyses.
 Conclusion: PNET originates most often from the chest
 wall, so it is advisable to start the X-ray examination from
 the chest. In terms of radiation semiotics, PNET is similar to
 Ewing’s sarcoma and Askin’s tumor; therefore, an additional
 immunohistochemical study of the tumor tissue is required.
 An important indirect diagnostic criterion in Ewing’s sarcoma
 is the predominance of the soft tissue component over the
 bone manifestations. Extended CT and MRI studies with contrast enhancement (chest, abdominal cavity, pelvis, and the
 primary lesion area) and skeletal scintigraphy are required to
 clarify the extent of changes, stage the tumor accurately, and
 assess the tumor dynamics after treatment. The above conclusions generally coincide with the available literature data.

Juvenile Aggressive Ossifying Fibroma of Paranasal Sinuses: An Unusual Presentation in an 18-Year-Old Female

Abstract Juvenile aggressive ossifying fibroma (JAOF) is a rare variant of ossifying fibroma. Conventional ossifying fibromas are slow growing neoplasms thought to originate from osseous mesenchyme, commonly arising in the mandible. Conversely, JAOF occurs more frequently in the paranasal bones with rapid growth leading to local destruction, facial asymmetry, nasal obstruction, and proptosis. JAOF has two microscopic variants, psammomatoid and trabecular. Most JAOFs occur in patients less than 12-years-old with slight male predominance. We present an 18-year-old female with facial asymmetry for two years duration and recent onset of severe headaches. Examination revealed a bulging left maxillary bone and left upward proptosis. MRI showed an 81.2 × 44 × 39 mm, lobulated, well-defined, expansile osseous lesion with calcified matrix and soft tissue component involving the left maxillary sinus with extension into the left nasal cavity, frontal and ethmoid sinuses, and left orbit. An endoscopic biopsy procedure was performed to reveal sinonasal mucosa infiltrated by a cellular, fibro-osseous neoplasm consisting primarily of numerous, closely packed, round, uniform basophilic psammoma bodies with eosinophilic rings, interspersed by cellular, benign fibroblastic proliferations. Cystic changes and foci of necrosis were also noted. Complete excision of the JAOF is critical as recurrence and corresponding complications may develop in up to 50% of patients.

Arthroscopic treatment of anteromedial ankle impingement

Objective: Impingement syndromes are recognized as an important cause of chronic ankle pain, which results from the entrapment of an inflamed soft-tissue component between the osteophytes. The predominant site of occurrence is the anterolateral aspect of the ankle for soft-tissue impingement, and anteromedial aspect for bony impingement. Symptoms related to the physical impact of bone or soft-tissue pain often result in limited ankle range of motion. Methods: We conducted a retrospective study of 34 patients (34 ankles) with anteromedial bony impingement. All patients underwent arthroscopy, with a mean follow-up of 34 months. Results: All osteophytes were removed, and the ankle range of motion improved. The AOFAS score improved from 73 preoperatively to 95 postoperatively. Conclusion: The arthroscopic removal of the anteromedial osteophytes of the ankle had excellent functional results. It is an effective procedure that allows rapid patient recovery. Level of Evidence IV; Therapeutic Studies; Case Series.

Chondrosarcoma local recurrence in the Cancer Registry of Norway cohort (1990-2013): Patterns and impact.

There appears to be an association between local recurrence (LR) and risk of metastasis and death in central conventional chondrosarcoma (CCCS) of bone, but this has not been quantified in modern cohorts at a subtype level. We identified nonmetastatic cases of CCCS (N = 180) from the Cancer Registry of Norway. We present prognostic analysis of LR accounting for immortal time bias by descriptive statistics and multivariable Cox models. Of 40 LR, one case demonstrated upgrading while two dedifferentiation. LR was associated with increased risk of metastasis (hazard ratio [HR] = 4.1 [confidence interval, 1.5-10.7]) and death (HR = 9.3 [5.0-17.5]) overall. LR was associated with significant increased risk of metastasis for those with a soft tissue component, axial location, malignancy grade 2, but not atypical cartilaginous tumor's, appropriately treated curettage patients, intramedullary tumors, grade 1 histology, extremity location or "Oslo low risk" group status. We found an increased risk of death for all groups except for those treated by appropriate curettage or belonging to the "Oslo low risk" group. About 50% of LR CCCS were asymptomatic and revealed by routine follow-up. Upgrading of LR for CCCS was a seldom event. LR was associated with significant increased risk of metastasis and death overall, but not for appropriately treated curettage patients or "Oslo low risk" status.

Observations on the growth of temporalis muscle: A 3D CT imaging study.

This study investigates the hypothesis that there is, during childhood, a disproportionate age-related expansion of the origin of temporalis muscle compared to the growth of the underlying skull. Lateral projections of 50 randomly selected 3D reformatted computerized tomographic (CT) scans (yielding 100 temporalis muscles) of children aged >0.6 to 15years scanned for conditions that did not affect the shape of their head or face were windowed to provide the optimum delineation of temporalis muscle against the underlying bone. Vertical and anterior-posterior measurements of the muscle made independently by two observers were compared with those of the skull along the same planes. The development of the anterior temporal crest was also assessed. The intraclass correlation coefficient for differences in the measurements made by each observer ranged from good to excellent. The muscle and skull measurements were used to produce a ratio of muscle-to-skull lengths in both vertical and horizontal planes. Analysis of these ratios showed a statistically significant increase in the vertical reach of temporalis with age (Pearson correlation coefficient (R)=0.7826; p<0.05) compared to the growth of the skull along the planes chosen for the study-but less so for its horizontal reach (R=0.5073. p<.001). There were no significant differences between right/left or male/female measurements. There was also a substantial level of agreement between both observers in their assessment of the development of the temporal crest. The mean age of children in whom a fully formed temporal crest could be identified (10.6years) was significantly greater (p<0.001) than that of the 38 remaining subjects (6.0years). These results confirm that there is, in response to increased masticatory/dietary demands during childhood, a disproportionate increase in the vertical and (to a lesser extent) horizontal reach of temporalis muscle over its origin from the temporal, frontal, sphenoid, and parietal bones compared the growth of the skull. It is proposed that surgical interference with this normal process is responsible for the soft tissue component of late-developing deformity that can occur following early (at 6-18months of age) operations for the correction of trigonocephalic head shape associated with metopic synostosis.

Structural stiffening in the human middle ear due to static pressure: Finite-element analysis of combined static and dynamic middle-ear behavior

The vibration response of the middle ear (ME) to sound changes when static pressure gradients are applied across the tympanic membrane (TM). To date, it has not been well understood which mechanisms lead to these changes in ME vibration response. In this study, a 3D finite-element model of the human ME was developed that simulates the sound-induced ME vibration response when positive and negative static pressures of up to 4 kPa are applied to the TM. Hyperelasticity of the soft-tissue components was considered to simulate large deformations under static pressure. Some ME components were treated as viscoelastic materials to capture the difference between their static and dynamic stiffness, which was needed to replicate both static and dynamic ME behavior. The change in dynamic stiffness with static preload was simulated by linearization of the hyperelastic constitutive model around the predeformed state. For the preloaded harmonic response, we found that the statically deformed ME geometry introduced asymmetry in the vibration loss between positive and negative pressure, which was due to the TM cone shape. As opposed to previous assumptions, the prestress in the ME due to static pressure had a substantial impact on the vibration response. We also found that material nonlinearity led to a higher stiffening at the umbo but a less pronounced stiffening at the footplate compared to the linear elastic condition. The results suggest that flexibility of the incudomalleolar joint (IMJ) enhances the decoupling of static umbo and footplate displacements, and that viscosity and viscoelasticity of the IMJ could play a role in the transfer of sound-induced vibrations from the umbo to the footplate. The components of the incudostapedial joint had minimal effect on ME mechanical behavior.

Axillary Fibromyxoid Sarcoma with an Aspergillus Niger in a Tumor Cavity Compressing the Chest Wall: A Rare Tumor with Fungus

Axillary tumors constitute about 0.11% of all malignancies. More rare tumors arise from the soft tissue component of the body that includes muscles, nerves, or 􀏐ibrous tissues. Low-Grade Fibromyxoid Sarcoma (LGFMS) is a rare, malignant, soft tissue tumor often seen in young and middle-aged adults. A number of cases are found in the literature of LGFMS that can arise from different locations like thigh, breast, head, neck, masseter muscle, uterine cavity, and mesentery, but a huge axillary 􀏐ibro-myxoid sarcoma with Aspergillus Niger fungal infection within the sarcoma cavity is not yet reported. We present here a young male with a two-year history of painful swelling in the right axillary region which was foul-smelling with a discharging sinus containing pus. The patient was empirically treated with anti-tuberculous drugs and was also operated twice. The patient was admitted, and a chest computed tomography scan with contrast was done which showed an asymmetrical right chest with a large heterogeneous mass in the right posterosuperior aspect of the chest wall extending into the axillary region. Operatively the draining sinus along with the mass was excised and sent for histopathology. A 17-18x8 cm hard calci􀏐ied capsule was removed. On crosssection, a thick hard cavity laden with debris was noted. Immunohistopathology con􀏐irmed a low-grade 􀏐ibro-myxoid sarcoma. Therefore, a discharging chest wall sinus should be reviewed. Broad differentials including tuberculosis must be ruled out especially after effective anti-tuberculous therapy. The risk of metastasis is signi􀏐icantly reduced with ef􀏐icient excision and aggressive surgical intervention reducing further risk of future complications.

English

BACKGROUND Chordomas are tumours presumed to originate from the remnants of embryonic notochord. They present a diagnostic challenge as they can occur in any region within the craniospinal axis and are rare with an incidence of less than 0.1 / 100,000 per year. Imaging is required for their evaluation and magnetic resonance imaging (MRI) is the imaging modality of choice due to excellent soft tissue resolution, multiplanar imaging capabilities and precise anatomical delineation. METHODS MRI scans of 10 patients, who had proven chordomas histologically, were evaluated retrospectively in the Department of Radiodiagnosis, Bangur Institute of Neurosciences from July 2012 to June 2018. Patients without histological proof of chordomas and those lost to follow-up were not included in the study. Clinical information such as age, sex, presenting symptoms were noted. Imaging parameters assessed included tumour location, bone destruction, extraspinal soft tissue component, spinal canal and neural foramina encroachment, arterial encasement, signal intensity, morphology and enhancement pattern by MRI. All the cases were scanned in a 1.5 Tesla MRI machine. Intravenous contrast were used in all cases. RESULTS Of the 10 cases, 7 were male and 3 were female. There were 7 cases of sacrococcygeal chordomas and 3 cases of clival chordomas. The tumours appeared as multilobulated masses with bone destruction. All sacrococcygeal lesions involved more than one vertebral segment with extraspinal soft tissue component encroaching the pelvic cavity and showed cystic spaces containing hypointense septae. All 3 cases of clival chordomas showed compression of the pons and basilar artery. In one case there was compression of optic chiasma with displacement of internal carotid arteries laterally. On T1 weighted imaging, the chordomas were isointense in 4 and hypointense in 6 cases. These tumours were hyperintense in T2WI in 8 and intermediate to high in signal intensity in 2 cases. All demonstrated heterogenous enhancement on contrast with moderate enhancement in 8 patients and mild enhancement in 2 cases. CONCLUSIONS Chordomas are rare tumours that can occur anywhere in the craniospinal axis. MRI is the modality of choice for imaging of chordomas. Characteristic findings in MRI include low to intermediate signal intensity on T1w images and high signal intensity on T2w images. Sacral chordomas have T2 hyperintense cystic masses with hypointense septa. Enhancement is heterogenous ranging from mild to moderate. MRI is invaluable for a pre-operative diagnosis, delineation of tumour extent and as roadmap for surgery and radiotherapy. KEYWORDS Chordomas, Magnetic Resonance Imaging, Clivus, Sacrococcygeal

A Novel 3-Dimensional Printing Fabrication Approach for the Production of Pediatric Airway Models.

BACKGROUND:Pediatric airway models currently available for use in education or simulation do not replicate anatomy or tissue responses to procedures. Emphasis on mass production with sturdy but homogeneous materials and low-fidelity casting techniques diminishes these models’ abilities to realistically represent the unique characteristics of the pediatric airway, particularly in the infant and younger age ranges. Newer fabrication technologies, including 3-dimensional (3D) printing and castable tissue-like silicones, open new approaches to the simulation of pediatric airways with greater anatomical fidelity and utility for procedure training.METHODS:After ethics approval, available/archived computerized tomography data sets of patients under the age of 2 years were reviewed to identify those suitable for designing new models. A single 21-month-old subject was selected for 3D reconstruction. Manual thresholding was then performed to produce 3D models of selected regions and tissue types within the dataset, which were either directly 3D-printed or later cast in 3D-printed molds with a variety of tissue-like silicones. A series of testing mannequins derived using this multimodal approach were then further refined following direct clinician feedback to develop a series of pediatric airway model prototypes.RESULTS:The initial prototype consisted of separate skeletal (skull, mandible, vertebrae) and soft-tissue (nasal mucosa, pharynx, larynx, gingivae, tongue, functional temporomandibular joint [TMJ] “sleeve,” skin) modules. The first iterations of these modules were generated using both single-material and multimaterial 3D printing techniques to achieve the haptic properties of real human tissues. After direct clinical feedback, subsequent prototypes relied on a combination of 3D printing for osseous elements and casting of soft-tissue components from 3D-printed molds, which refined the haptic properties of the nasal, oropharyngeal, laryngeal, and airway tissues, and improved the range of movement required for airway management procedures. This approach of modification based on clinical feedback resulted in superior functional performance.CONCLUSIONS:Our hybrid manufacturing approach, merging 3D-printed components and 3D-printed molds for silicone casting, allows a more accurate representation of both the anatomy and functional characteristics of the pediatric airway for model production. Further, it allows for the direct translation of anatomy derived from real patient medical imaging into a functional airway management simulator, and our modular design allows for modification of individual elements to easily vary anatomical configurations, haptic qualities of components or exchange components to replicate pathology.

Lipoblastoma: computed tomographic and magnetic resonance imaging features correlate with tumor behavior and pathology.

Lipoblastoma is a rare benign neoplasm of immature fat cells in children. Imaging appearances are frequently complex, sometimes simulating liposarcoma. To characterize features of lipoblastoma on MRI and CT in comparison with recurrence risk. We identified cases via retrospective review of histopathology-proven lipoblastoma cases in a large referral database and a pediatric medical center. Two radiologists scored CT and MRI on the basis of lesion features. We included a total of 56 children (32 boys and 24 girls) with a mean age of 2.6years (range 0.1-13years). Extremity lesions were most common (27%), followed by neck (19%), gluteal region (18%), chest (14%) and mesentery (14%). Children most commonly presented with painless masses (73%), followed by dyspnea (9%), distension (9%) and pain (7%). Non-adipose soft-tissue components were identified on CT and MRI in 78% of cases. Significant (moderate or marked) septations were noted in 59% and enhancement in 35%. Compartmental invasion was present in 43% of cases. Of paraspinal cases, 38% involved the neural foramina or central canal. Lesion complexity did not significantly correlate with age. Recurrence was observed in 9% of cases and was significantly correlated with compartmental invasion (correlation: 0.303, P=0.009) and septation complexity (correlation: 0.227, P=0.038) on initial imaging. Although lipoblastoma is a fat-containing entity, many lesions demonstrate marked complexity and local infiltration that resemble liposarcoma, which is exceedingly rare in younger children. Compartmental invasion and thicker septations appear to confer greater risk of recurrence following resection.

A deep learning approach to generate contrast-enhanced computerised tomography angiograms without the use of intravenous contrast agents

Abstract Introduction Contrast-enhanced computerised tomographic (CT) angiograms are widely used in cardiovascular imaging to obtain a non-invasive view of arterial structures. In aortic aneurysmal disease (AAA), CT angiograms are required prior to surgical intervention to differentiate between blood and the intra-luminal thrombus, which is present in 95% of cases. However, contrast agents are associated with complications at the injection site as well as renal toxicity leading to contrast-induced nephropathy (CIN) and renal failure. Purpose We hypothesised that the raw data acquired from a non-contrast CT contains sufficient information to differentiate blood and other soft tissue components. Therefore, we utilised deep learning methods to define the subtleties between the various components of soft tissue in order to simulate contrast enhanced CT images without the need of contrast agents. Methods Twenty-six AAA patients with paired non-contrast and contrast-enhanced CT images were randomly selected from an ethically approved ongoing study (Ethics Ref 13/SC/0250) and used for model training and evaluation (13/13). Non-contrast axial slices within the aneurysmal region from 10 patients (n=100) were sampled for the underlying Hounsfield unit (HU) distribution at the lumen, intra-luminal thrombus and interface locations, identified from their paired contrast axial slices. Subsequently, paired axial slices within the training cohort were augmented in a ratio of 10:1 to produce a total of 23,551 2-D images. We trained a 2-D Cycle Generative Adversarial Network (cycleGAN) for this non-contrast to contrast transformation task. Model output was assessed by comparison to the contrast image, which serves as a gold standard, using image similarity metrics (ex. SSIM Index). Results Sampling HUs within the non-contrast CT scan across multiple axial slices (Figure 1A) revealed significant differences between the blood flow lumen (yellow), blood/thrombus interface (red), and thrombus (blue) regions (p&amp;lt;0.001 for all comparisons). This highlighted the intrinsic differences between the regions and established the foundation for subsequent deep learning methods. The Non-Contrast-to-Contrast (NC2C)-cycleGAN was trained with a learning rate of 0.0002 for 200 epochs on 256 x 256 images centred around the aorta. Figure 1B depicts “contrast-enhanced” images generated from non-contrast CT images across the aortic length from the testing cohort. This preliminary model is able to differentiate between the lumen and intra-luminal thrombus of aneurysmal sections with reasonable resemblance to the ground truth. Conclusion This study describes, for the first time, the ability to differentiate between visually incoherent soft tissue regions in non-contrast CT images using deep learning methods. Ultimately, refinement of this methodology may negate the use of intravenous contrast and prevent related complications. CTA Generation from Non-Contrast CTs Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Clarendon

Establishing the Prevalence of Complicated Bone Metastases in Community Radiation Oncology Clinics

Numerous randomized trials have established the noninferiority of single-fraction radiation therapy (RT) to multi-fraction RT for palliation of painful bone metastases. Yet most used complicating features as exclusion criteria, and a clear definition and understanding of the prevalence of such features is lacking, particularly in community settings. To further characterize this prevalence outside of a tertiary-care setting, we performed a retrospective review of community-treated patients. A retrospective review of the electronic medical record was performed for patients treated with palliative RT to symptomatic bone sites between 5/2013 and 5/2016 in two community hospital-based radiation oncology clinics. Baseline demographic, disease, and treatment data were collected as well as the presence of potential complicating features including history of prior RT, prior surgery, pathologic fracture, and neuraxis compromise at the RT treatment site. Descriptive statistics summarized rates of complicating features. Two-sample tests of proportions quantified the difference (diff) in rates of complicating features between the present population vs. published rates from a tertiary-care center. Cox regressions were performed to determine the effect of complicating features on survival. Among 182 patients, 216 bone sites were treated. Median age was 68.9 years (range 25-94), 54.9% of patients were male, 73.6% were white, 17% were black, and 9.3% were another race. Median time from initial cancer diagnosis to RT consult was 14 months (standard deviation 47). The most common histology was breast (26%), followed by lung (23%), prostate (21%), hematologic malignancies (2%), and other histologies (28%). Symptomatic sites were spine (54%), hip/pelvis (16%), extremity (15%), chest wall (12%), and skull (4%). Among all patients, 54.2% had at least one complicating feature. Percent of target sites complicated by prior RT was 2.8% (diff: -.016, p = .30), prior surgery 10.2% (diff: .013, p = .56), pathologic fracture 31.5% (diff: .109, p = .0009), and soft tissue component 35% (diff: -.036, p = .34). Among 151 spine and medial pelvis sites, there was evidence of neuraxis compromise in 51% of cases (diff: -.01, p = .83). Prior surgery was associated with longer survival time (HR: .56; p = .031), but no other complicating features demonstrated a significant effect on survival. Complicating features of bone metastases are common and occur at similar rates in both tertiary-care and community hospital-based radiation oncology clinics. Aside from prior surgery at the RT site, there were no additional associations between complicating features and survival time in this population. Given the high prevalence of complicating features, these results support the need for future studies aimed at characterizing optimal management for complicated bone metastases.

Outcomes and Toxicity of Single- And Multi-Fraction Spine Radiosurgery for Three or More Vertebral Bodies

Spine radiosurgery is an accepted standard treatment for vertebral body metastases and is traditionally restricted to one or two consecutive vertebral bodies due to toxicity concerns with larger volumes. Thus, the outcomes and toxicity of radiosurgery to a larger volume of three or more vertebral bodies are poorly characterized. We sought to describe our single-institution experience of treating patients with radiosurgery to three or more consecutive vertebral bodies. An IRB-approved retrospective review of our prospectively maintained radiosurgery database was performed. Inclusion criteria were men and women receiving single- or multi-fraction spine radiosurgery to three or more consecutive vertebral bodies with at least one month of follow-up. We recorded outcome data such as local control, overall survival, and pain response. Local progression was defined as radiologic progression, recurrent pain in the treatment field, or a vertebral body metastasis in the body adjacent to the treatment volume. Pain scores (scored 0-10) in the treated area were evaluated within one month before treatment and in longer follow-up. Average change in pain score after treatment was reported. Karnofsky performance status (KPS) was also evaluated within one month before treatment and in follow up. KPS was based on debilitation from tumors at the treated site. Toxicity endpoints of interest were radiation myelopathy and vertebral body fracture. 32 patients were identified (18 male, 14 female), and 35 total sites were treated. Median age of patient at time of SRS treatment was 59. Median dose in single fraction was 1300cGy (range: 800-1800cGy), and median dose in multiple fractions was 2400cGy (range: 1800-3000cGy). 21% of patients had cervical spine metastases, 55% with thoracic spine metastases, and 24% with lumbar spine metastases, with primary tumor sites including colon, breast, thymus, pelvis, lung, mammary gland, kidney, thyroid, nasopharynx, rhabdomyosarcoma, bone, schwannoma, and vulva. 14/32 (43%) patients had epidural or paraspinal soft tissue components of their disease. The six-month local control rate was 77%. The one-year survival rate was 49%. Average change in pain score was -.5 (range: -7-+4, st dev ±2.55). Median pre-treatment KPS was 90%, and median post-treatment KPS was 80%, with 7/32 (22%) patients having a decline in 20% or greater, and 2/32 (6.2%) patient having an improvement of 20% or greater. Incidence of vertebral compression fracture was 4/32 (12.5%), and radiation myelopathy was 0/32 (0%). Treatment of patients with radiosurgery to three or more consecutive vertebral body metastases is well tolerated. For the majority of treated patients, single- or multi-fraction radiosurgery provides durable local control, modest pain relief, preserved quality of life, and low rates of severe toxicity.

Role of Diffusion-Weighted and Chemical Shift Magnetic Resonance Imaging in Differentiation of Benign and Malignant Spinal Fractures

Atraumatic spinal compression fractures are common clinical problem. Differentiating benign osteoporotic fractures from pathological fractures due to malignant/metastatic lesions affects the management and prognoses in patients with known extraspinal malignancy. The objective of the research was to assess the role of conventional magnetic resonance imaging sequences with diffusion-weighted imaging and chemical-shift imaging in differentiating benign and malignant acute spinal compression fractures.&#x0D; Materials and Methods. The study included 40 patients with acute spinal compression fractures. Patients were evaluated using magnetic resonance imaging with diffusion-weighted imaging and chemical-shift imaging to differentiate benign etiology from malignant one. The results obtained were compared with histopathological follow-up for 6 months for definite clinical diagnoses.&#x0D; Results. No significant difference was noted in signal characteristics of benign and malignant fractures on T1, T2 and short-tau inversion recovery. However, posterior element involvement, soft tissue component and post-contrast enhancement were seen more frequently in malignant fractures (p&lt;0.05). On diffusion-weighted images, 77.8% of malignant fractures were hyperintense and 59.1% of benign fractures were hypointense (p&lt;0.05). The mean apparent diffusion coefficient value was 0.81 ± 0.19 for malignant and 1.24 ± 0.24 for benign fractures (p&lt;0.5). The mean signal intensity ratio for malignant fractures was 0.91 ± 0.125, whereas the signal intensity ratio for benign fractures was 0.64 ± 0.096 (p&lt;0.001).&#x0D; Conclusions. Signal characteristics on T1, T2 and short-tau inversion recovery sequences do not differentiate benign from malignant fractures; however, posterior element involvement, soft tissue and post contrast enhancement help in differentiating the etiology. Diffusion-weighted imaging and apparent diffusion coefficient values, as well as using chemical shift imaging further improve the diagnostic accuracy of magnetic resonance imaging.

Flap delineation guidelines in postoperative head and neck radiation therapy for head and neck cancers

IntroductionReconstructive surgery in head and neck cancers frequently involves the use of autologous flaps to improve functional outcomes. However, the literature suggests that postoperative radiotherapy deteriorates functional outcomes due to flap atrophy and fibrosis. Data on patterns of relapse after postoperative radiotherapy with a flap are lacking, resulting in heterogenous delineation of postoperative clinical target volumes (CTV). Flap delineation is unusual in routine practice and there are no guidelines on how to delineate flaps. Therefore, we aim to propose a guideline for flap delineation in head and neck cancers to assess dose-effects more accurately with respect to flaps. Material and methodsCommon flaps were selected. They were delineated by radiation oncologists and head and neck surgeons based on operative reports, on contrast-enhanced planning CTs and checked by a radiologist. Each flap was divided into its vascular pedicle and its soft tissue components (fat, fascia/ muscle, skin, bone). ResultsDelineation (body and pedicle) of Facial Artery Musculo-Mucosal, pectoralis, radial forearm, anterolateral thigh, fibula and scapula flaps was performed. Based on information provided in operative reports, i.e. tissue components, size and location, flaps can be identified. The various tissue components of each flap can be individualized to facilitate the delineation. ConclusionThis atlas could serve as a guide for the delineation of flaps and may serve to conduct studies evaluating dose-effects, geometric patterns of failure or functional outcomes after reconstructive surgery. Changes in postoperative CTV definitions might be needed to improve risk/benefit ratio in the future based on surgery-induced changes.

Juxtacortical Osteosarcoma-Imaging Spectrum

Juxtacortical Osteosarcoma (OS) presents with three sub-types. These include parosteal OS, periosteal OS, and Highgrade surface OS. Imaging diagnosis of sub-types of Juxtacortical osteosarcoma is difficult. However, an analysis of 14 cases of these sub-types presents a spectrum of findings in each entity. The analysis of the Site, Transitional zone, Age, Matrix mineralization, Periosteal reaction, and Soft tissue component (STAMPS) are essential in making the final diagnosis and differential diagnosis.

Sarcomatous Transformation of Unicentric Calcaneal Epithelioid Hemangioendothelioma: A Case Report with Review of Literature

Vascular origin tumors of bone are rare entities. Epithelioid hemangioendothelioma (EHE) is a rare tumor representing &lt;1% of primary bone tumors and is considered a low to intermediate grade malignancy. Literature describes cases which were either a part of multicentric disease or were metastatic. In this study, we reported a case of a 23-year-old female with biopsy-proven EHE with prior history of resection, presenting with recurrence of disease. Radiographs showed a lytic lesion involving the left calceneum and other tarsal bones with extensive soft-tissue component. Magnetic resonance imaging revealed an ill-defined, enhancing, lobular, and lytic lesion with adjacent soft-tissues component. Computed tomography confirmed extensive destruction of the involved tarsal bones. EHE is treated with wide surgical excision and recurrence is rare; however, our case presented with recurrence as well as thoracic metastasis which posed a great clinical challenge. The patient was treated with below knee amputation and was given subsequent radiotherapy. The main aim of this study is to revisit the clinicopathological aspects as well as the spectral behavior of vascular bone tumors.