Carlo Faletti

Ultrasound and magnetic resonance imaging in sports-related muscle injuries

Purpose.The objective of this study was to evaluate the role of magnetic resonance imaging (MRI) and ultrasonography (US) in the diagnosis of traumatic muscle injuries.Materials and methods.From June 2003 to June 2004, 81 football players with a history of traumatic muscle injuries to the lower limbs were examined. US was performed shortly after the trauma (from 6 to 72 h afterwards) and MRI within a maximum of 5 days.Results.MRI revealed 26 minor and 55 major traumas. MRI and US showed complete concordance in 71 patients (site, type and extent of injury). US produced ten false negative results, including six minor lesions and four major lesions. US had a sensitivity of 87.65% in the correct identification of muscle injuries; its sensitivity was 92.72% for major lesions and 76.92% for minor lesions, 57% for delayed-onset muscle soreness (DOMS), 80% for lengthenings, 83% for contractures, 84% for strains, 87.5% for mild contusions and 100% for severe contusions.Conclusions.US is the first-line technique for examination of muscle injuries. MRI is able to reveal lesions that may be missed at US and provide a more accurate assessment of site and extent of injury.

Accuracy of core-needle biopsy after contrast-enhanced ultrasound in soft-tissue tumours

ObjectivePercutaneous biopsies are gaining acceptance in the diagnosis of soft-tissue tumours. Sampling in the most representative area is not easy in sarcomas of huge dimension. We hypothesised that ultrasound (US) contrast medium could identify the representative area for focus core-needle biopsy (CNB)MethodsThis is a retrospective cohort series of 115 soft-tissue masses treated from January 2007 to November 2008. Accuracy of US-guided CNB after contrast-enhanced US (CEUS) was determined by comparing the histology of the biopsy with the definitive diagnosis in 105 surgically excised samples (42 benign, 63 malignant) and with the expected outcome in the remaining ten malignant cases not surgically treated. A myxoid component was present in 21 sarcomas (34.4%).ResultsOf samples, 94.8% were adequate for diagnosis with 97.1% sensitivity and 92.5% specificity. Sensitivity and specificity in specific histopathological subgroupings were 100%, and in grading definition they were 100% and 96.8%.DiscussionUS-guided CNB is safe and effective. US contrast medium depicts tumour vascular supply and identifies the representative area(s) for sampling. Sensitivity and specificity are also high in subgrouping and grading, including myxoid types. Discussion about biopsy is part of the essential multidisciplinary strategy for these tumours.

Musculoskeletal tumours: preliminary experience with perfusion MRI

PurposeOur study aimed to assess the role of magnetic resonance imaging (MRI) in the characterisation of musculoskeletal tumours and to identify specific perfusion patterns for the different tumours.Materials and methodsBetween January 2003 and September 2005, we evaluated the conventional and perfusion MRIs of 39 patients with musculoskeletal tumours. Dynamic MRI was performed with a 1.5-T and 1.0-T MRI unit before and after the intravenous administration of contrast material, using dedicated phased-array coils appropriate for the region to be studied and fast and ultrafast consecutive sequences. Postprocessing was done on an independent workstation (Advantage Windows, GE Medical System), with Functool (GE) software, which allowed a quantitative evaluation of enhancement as a function of time. The results were compared with the histopathological diagnoses obtained by biopsy or surgery.ResultsThe lesions identified in the 39 patients included 23 soft tissue tumours (12 benign, 11 malignant) and 16 bone tumours (ten benign, six malignant). Comparing the time-intensity diagrams of lesions of the same histological type, we found typical enhancement patterns for some bone tumours only, especially for bone, cartilaginous, fibrohistiocytic and pseudoinflammatory lesions. No typical enhancement pattern could be detected for any of the histological types of soft tissue tumour. Analysis of the slope of the time-intensity curves has a sensitivity and specificity of 64%–58% for soft tissue tumours and 86%–67% for bone tumours in determining the biological aggressiveness of the lesions.ConclusionsPerfusion MRI had moderate sensitivity and specificity in the differential diagnosis between lesions with high or low biological activity. Only in a few cases was it possible to find some correlation between perfusion patterns and lesion histology. The slope values should therefore be used in combination with conventional spin-echo images and other imaging and clinical data in order to narrow the field of the possible differential diagnoses and reliably predict the nature of the lesion.RiassuntoScopoValutare il ruolo della RM perfusionale nella caratterizzazione delle neoformazioni muscoloscheletriche; in particolare lo studio è volto alla ricerca di pattern perfusionali patognomonici per i diversi istotipi tumorali.Materiali e metodiNel periodo compreso tra gennaio 2003 e settembre 2005 sono stati valutati gli esami RM standard e RM perfusionali di 39 pazienti. Gli esami RM dinamici sono stati eseguiti con apparecchiature RM dotate di un magnete da 1,5 T e da 1,0 T, tramite bobine di superficie dedicate scelte in funzione del distretto da studiare prima e dopo somministrazione ev di MdC utilizzando sequenze rapide ed ultrarapide in successione. La post-elaborazione è stata eseguita in tutti i casi tramite il software Functool installato su una workstation indipendente (Advantage Windows, GE Medical System), che ha permesso, attraverso il posizionamento di una ROI, di effettuare una valutazione quantitativa dell’enhancement in funzione del tempo. I risultati sono stati confrontati con l’esame istologico ottenuto tramite biopsia o intervento chirurgico.RisultatiLe lesioni dei 39 pazienti esaminati sono risultate essere: 23 tumori dei tessuti molli di cui 12 benigni e 11 maligni e 16 lesioni ossee, di cui 10 benigne e 6 maligne. Confrontando le curve intensitàtempo (TIC) delle lesioni appartenenti ad uno stesso istotipo sono state identificate curve tipiche per alcune lesioni tumorali ossee (serie ossea, cartilaginea, fibroistiocitica) e per le lesioni infiammatorie. Non è stato possibile identificare una curva tipica all’interno dello stesso istotipo per le lesioni dei tessuti molli. È possibile valutare l’aggressività biologica delle lesioni muscolo-scheletriche tramite la pendenza delle curve intensità-tempo con livelli di sensibilità e di specificità che sono rispettivamente del 64%/58% per i tumori dei tessuti molli e del 86%/67% per i tumori ossei.ConclusioniLa RM perfusionale ha mostrato un discreto livello di sensibilità e specificità nella diagnosi differenziale tra lesioni ad elevata ed a bassa attività biologica e solo in alcuni casi è stato possibile riscontrare una correlazione tra pattern perfusionale e istologia della lesione. I valori di pendenza dovrebbero quindi essere usati insieme con le immagini spin echo convenzionali e con altri dati diagnostici e clinici per restringere le possibili diagnosi differenziali e per poter predire con una significativa attendibilità la natura della lesione.

Perfusion pattern and time of vascularisation with CEUS increase accuracy in differentiating between benign and malignant tumours in 216 musculoskeletal soft tissue masses

INTRODUCTION Musculoskeletal Soft Tissue Tumours (STT) are frequent heterogeneous lesions. Guidelines consider a mass larger than 5 cm and deep with respect to the deep fascia potentially malignant. Contrast Enhanced Ultrasound (CEUS) can detect both vascularity and tumour neoangiogenesis. We hypothesised that perfusion patterns and vascularisation time could improve the accuracy of CEUS in discriminating malignant tumours from benign lesions. MATERIALS AND METHODS 216 STT were studied: 40% benign lesions, 60% malignant tumours, 56% in the lower limbs. Seven CEUS perfusion patterns and three types of vascularisation (arterial-venous uptake, absence of uptake) were applied. Accuracy was evaluated by comparing imaging with the histological diagnosis. Univariate and multivariate analysis, Chi-square test and t-test for independent variables were applied; significance was set at p<0.05 level, 95% computed CI. RESULTS CEUS pattern 6 (inhomogeneous perfusion), arterial uptake and location in the lower limb were associated with high risk of malignancy. CEUS pattern has PPV 77%, rapidity of vascularisation PPV 69%; location in the limbs is the most sensitive indicator, but NPV 52%, PPV 65%. The combination of CEUS-pattern and vascularisation has 74% PPV, 60% NPV, 70% sensitivity. No correlation with size and location in relation to the deep fascia was found. CONCLUSION US with CEUS qualitative analysis could be an accurate technique to identify potentially malignant STT, for which second line imaging and biopsy are indicated in Referral Centers. Intense inhomogeneous enhancement with avascular areas and rapid vascularisation time could be useful in discriminating benign from malignant SST, overall when the lower limbs are involved.

Study of neurinomas with ultrasound contrast media: review of a case series to identify characteristic imaging patterns

PurposeThe aim of this study was to evaluate whether there exists a characteristic distribution pattern of vessels within neurinomas that may be used to characterise this type of lesion by employing a contrast-specific ultrasound technique.Materials and methodsBetween January 2003 and May 2010, 66 suspected neurinomas were evaluated according to their sonographic features (solid fusiform mass with well-defined margins located in direct continuity with the nerve that was not always discernible and heterogeneous as a result of the presence of small cystic areas or calcifications). The lesions were examined using a sonographic contrast medium consisting of sulphur hexafluoride microbubbles and equipment with dedicated contrast-specific software [contrast tuned imaging (CnTI)]. Of these lesions, five were excluded from the analysis because the definitive diagnosis was not available (in two cases, the follow-up was still in progress, whereas in the remaining three, there was no follow-up). Our study, therefore, is based on 61 surgically excised lesions that were confirmed to be neurinomas by histology, which is regarded as the gold standard.ResultsIn 41/61 cases (67.2%), we identified an enhancement pattern that we termed reticular owing to the interweaving of blood vessels, of which two subtypes were identified depending on whether the interwoven vessels were densely or sparsely packed: loose-knit reticular in 18/41, and tight-knit reticular in 23/41. In 20/61 (32.8%) cases, we observed a vascular pattern of diffuse heterogeneous enhancement, which was divided into two subtypes based on the presence of one (7/20) or more (13/20) avascular areas.ConclusionsResults showed that all neurinomas studied could be divided into two groups according to the type of enhancement pattern observed: reticular or diffuse heterogeneous.RiassuntoObiettivoScopo dello studio è valutare, mediante l’impiego di una tecnica ecografica contrasto-specifica, se esiste una distribuzione caratteristica dei vasi all’interno dei neurinomi che possa essere usata per una caratterizzazione del tipo di lesione.Materiali e metodiNel periodo compreso tra gennaio 2003 e maggio 2010 sono state valutate nel nostro dipartimento 66 lesioni sospette per neurinoma in base alle loro caratteristiche ecografiche (formazioni solide, fusiformi, a margini netti, in diretta continuità con la fibra nervosa, non sempre riconoscibile, disomogenee per l’eventuale presenza di piccole aree similcistiche o calcificazioni), ed esaminate con mezzo di contrasto (MdC) ecografico, costituito da microbolle a base di esafluoruro di zolfo e apparecchiatura dotata di software dedicato Contrast Tuned Imaging (CnTI) contrasto specifico. Di queste lesioni, 5 sono state escluse dall’analisi in quanto non era disponibile una diagnosi definitiva (n=2 follow-up in corso; n=3 assenza di follow-up). Pertanto il nostro studio si basa unicamente sulle 61 lesioni asportate chirurgicamente e confermate come neurinomi all’esame istologico, considerato come gold standard.RisultatiIn 41/61 (67,2%) casi abbiamo identificato una distribuzione del mezzo di contrasto definita “a reticolo” in base all’intreccio formato dalle strutture vascolari, in cui si riconoscono due sottotipi: “reticolo a maglie larghe” in 18/41 e “reticolo a maglie strette” in 23/41, distinti in base all’aspetto dell’incrocio dei vasi, se più rado o più fitto. In 20/61 (32,8%) casi abbiamo osservato un diverso pattern di vascolarizzazione, denominato “impregnazione diffusa disomogenea”, a sua volta suddiviso in due sottotipi in base alla presenza di una (7/20) o più aree avascolari (13/20).ConclusioniI risultati ottenuti in questo studio hanno dimostrato che tutti i neurinomi analizzati possono essere distinti in due gruppi, in base al tipo di pattern vascolare riscontrato: di tipo reticolare o ad impregnazione diffusa disomogenea.

Impingement Syndrome of the Lower Limb

The term “impingement” means the presence, in the joint area, of a formation originating from one of the components in that same joint and limiting function by effecting the biomechanics of movement. The impingement syndrome in the shoulder is defined as friction between skeletal components due to articular disequilibrium caused by injury to the tendons and ligaments.

Trauma of the Hand and Wrist

The hand and wrist are common sites for trauma, resulting in various bony, capsular, ligamentous and tendinous injuries. Traumatic injuries of the wrist are very frequent and occur at every age. Some lesions happen characteristically in a specific decade of life. Bone mineralization, which could be considered age-related, and ligamentous resistance and compliance, together with the mechanism of the trauma determine the resulting lesion [1-5]. Thus, metaphyseal fractures and slipping epiphysis typically occur in children. Both carpal dislocations and fracture-dislocations typically occur in young adults. Fractures, dislocations and fracture-dislocations of the distal extremity of radius and ulna usually occur in the elderly.

Diagnostic Algorithm in the Elderly

Our purpose in this chapter is to establish a linear, step-by-step procedure for use in musculoskeletal diagnostic imaging of elderly patients, describing some of the clinical peculiarities of old age and suggesting some specific technical choices. The authors start from the first symptoms that lead elderly patients to imaging, that is, pain (acute, breakthrough, or chronic), related to a traumatic lesion or a nontraumatic disease, to reach a clinical flowchart (algorithm). Consequently, the authors propose three flowcharts, one for axial trauma, one for appendicular skeletal trauma, and one for nontraumatic skeletal diseases to describe the procedures for diagnostic imaging in the elderly. The goal of this step-by-step procedure is to aid the diagnostician in sorting through the possible diagnoses and, if possible, to reach the correct diagnosis, and so approach the best therapy.