John E. Madewell

Pericardial cysts. A radiologic-pathologic correlation and review

Pericardial cysts are generally described as round radiodensities typically found at the right cardiophrenic angle in asymptomatic individuals. A review of all cases of pericardial cysts from the files of this Institute reveals that approximately one third of the cysts are found in other locations and that approximately one third of patients have symptoms of chest pain, dyspnea, or persistent cough. The radiographs of 41 patients show that in all but 6 of the cases the cyst is visualized as a round radiodensity touching both the hemidiaphragm and the anterior chest wall. Surprisingly, 15 of the 41 occurred on the left border of the heart. The six cysts significantly above the diaphragm were difficult to diagnosis radiologically and were usually mistaken for thymomas or pulmonary masses; two such cysts caused bronchial obstruction. In general, the possibility that a mass in either anterior cardiophrenic angle is a pericardial cyst should be strongly considered, even if the mass is on the left side and even if the patient is symptomatic.

18F-FDG PET/CT as an Indicator of Progression-Free and Overall Survival in Osteosarcoma

The aim of our study was to retrospectively evaluate whether maximum standardized uptake value (SUVmax), total lesion gylcolysis (TLG), or change therein using 18F-FDG PET/CT performed before and after initial chemotherapy were indicators of patient outcome. Methods: Thirty-one consecutive patients who underwent 18F-FDG PET/CT before and after chemotherapy, followed by tumor resection, were retrospectively reviewed. Univariate Cox regression was used to analyze for relationships between covariates of interest (SUVmax before and after chemotherapy, change in SUVmax, TLG before and after chemotherapy, change in TLG, and tumor necrosis) and progression-free and overall survival. Logistic regression was used to evaluate tumor necrosis. Results: High SUVmax before and after chemotherapy (P = 0.008 and P = 0.009, respectively) was associated with worse progression-free survival. The cut point for SUVmax before chemotherapy was greater than 15 g/mL* (P = 0.015), and after chemotherapy it was greater than 5 g/mL* (P = 0.006), as measured at our institution and using lean body mass. Increase in TLG after chemotherapy was associated with worse progression-free survival (P = 0.016). High SUVmax after chemotherapy was associated with poor overall survival (P = 0.035). The cut point was above the median of 3.3 g/mL* (P = 0.043). High TLG before chemotherapy was associated with poor overall survival (P = 0.021). Good overall and progression-free survival was associated with a tumor necrosis greater than 90% (P = 0.018 and 0.08, respectively). A tumor necrosis greater than 90% was most strongly associated with a decrease in SUVmax (P = 0.015). Conclusion: 18F-FDG PET/CT can be used as a prognostic indicator for progression-free survival, overall survival, and tumor necrosis in osteosarcoma.

Imaging bone metastases in breast cancer: techniques and recommendations for diagnosis

Bone is the most common site of distant metastases from breast carcinoma. The presence of bone metastases affects a patients prognosis, quality of life, and the planning of their treatment. We discuss recent innovations in bone imaging and present algorithms, based on the strengths and weaknesses of each technique, to facilitate the most successful and cost-effective choice of imaging studies for the detection of osseous metastases. Skeletal scintigraphy (bone scan) is very sensitive in the detection of osseous metastases and is recommended as the first imaging study in patients who are asymptomatic. Radiographs are recommended for the assessment of abnormal radionuclide uptake or the risk of pathological fracture and as initial imaging studies in patients with bone pain. MRI or PET-CT can be considered for cases of abnormal radionuclide uptake that are not addressed by radiography. Osseous metastases can lead to emergent situations, such as spinal-cord compression or impending fracture of a weight-bearing bone, and imaging guidelines are essential for early detection and initiation of appropriate therapy. The imaging method used in non-emergent situations, such as assessment of the ribs, sternum, pelvis, hips, and joints, should be guided by the strengths and limitations of each technique.

FDG-PET/CT Compared with Conventional Imaging in the Detection of Distant Metastases of Primary Breast Cancer

PURPOSE Evidence from studies with small numbers of patients indicates that (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) accurately detects distant metastases in the staging of primary breast cancer. We compared the sensitivity and specificity of PET/CT and conventional imaging (CT, ultrasonography, radiography, and skeletal scintigraphy) for the detection of distant metastases in patients with primary breast cancer. PATIENTS AND METHODS We performed a retrospective review that identified 225 patients with primary breast cancer seen from January 2000 to September 2009 for whom PET/CT data were available for review. Imaging findings were compared with findings on biopsy, subsequent imaging, or clinical follow-up. Sensitivity and specificity in the detection of distant metastases were calculated for PET/CT and conventional imaging. Fishers exact tests were used to test the differences in sensitivity and specificity between PET/CT and conventional imaging. RESULTS The mean patient age at diagnosis was 53.4 years (range, 23-84 years). The sensitivity and specificity in the detection of distant metastases were 97.4% and 91.2%, respectively, for PET/CT and 85.9% and 67.3%, respectively, for conventional imaging. The sensitivity and specificity of PET/CT were significantly higher than those of conventional imaging (p = .009 and p < .001, respectively). Eleven cases of distant metastases detected by PET/CT were clinically occult and not evident on conventional imaging. CONCLUSION PET/CT has higher sensitivity and specificity than conventional imaging in the detection of distant metastases of breast cancer. A prospective study is needed to determine whether PET/CT could replace conventional imaging to detect distant metastases in patients with primary breast cancer.

Primary Malignant Renal Tumors in the Second Decade of Life: Wilms Tumor Versus Renal Cell Carcinoma

Primary renal malignancies occur least frequently in the second decade of life. Of the 4,798 cases of renal cell carcinoma and Wilms tumor referred to the Armed Forces Institute of Pathology 53 renal cell carcinomas and 56 Wilms tumors occurred in the 10 to 20-year age group. Pathologically, both tumors in this age range are similar to those occurring at a more typical age, and histologic differentiation between renal cell carcinoma and Wilms tumor is seldom a problem. While radiographic evaluation is useful to characterize the neoplasm, evaluate the contralateral kidney and detect the presence of tumor extension, current imaging techniques cannot confidently distinguish these 2 tumors.

Chemotherapy response is an important predictor of local recurrence in ewing sarcoma

Local recurrence in Ewing sarcoma is associated with a poor prognosis. The purpose of the study was to determine the factors that predict local recurrence after surgical treatment of the primary tumor.

Computed tomography scan‐driven selection of treatment for retroperitoneal liposarcoma histologic subtypes

Well differentiated (WD) and dedifferentiated (DD) retroperitoneal liposarcoma (RPLS) have distinct biologic behaviors. Consequently, the therapeutic approaches for these tumors differ and mandate an accurate preoperative diagnosis. The authors of this report evaluated whether computed tomography (CT) can be used to differentiate between WD and DD RPLS.

FDG PET/CT of Primary Bone Tumors

OBJECTIVE Numerous primary bone tumors are encountered on (18)F-FDG PET/CT, and many are FDG avid. The degree of FDG uptake in bone tumors does not necessarily reflect malignant potential. In conjunction with radiographs, evaluation of morphologic characteristics on the CT portion of PET/CT scans is important for characterization of the lesions. FDG PET/CT has been found to be useful for staging and has also been found to reflect prognosis in some primary bone malignancies. The purpose of this article is to familiarize the reader with topics regarding FDG PET/CT and both malignant and benign primary bone tumors. CONCLUSION FDG uptake alone is not adequate for characterizing primary bone tumors, and morphologic evaluation is an important factor in the interpretation of PET/CT scans. After diagnosis, FDG avidity and morphologic features can play an important role in staging and determining response to therapy. On completion of this article, readers should have an improved ability to evaluate the FDG uptake and CT morphologic features of malignant and benign primary bone tumors. Readers should also have a better understanding of the potential role of FDG PET/CT in the management of patients with osteosarcoma and Ewing sarcoma.

Fast dixon-based multisequence and multiplanar MRI for whole-body detection of cancer metastases

To develop and demonstrate the feasibility of multisequence and multiplanar MRI for whole‐body cancer detection.

Multiple skeletal fibroxanthomas: radiologic-pathologic correlation of 72 cases

Out of a series of 900 biopsy-proven cases of skeletal “fibroxanthoma” (nonossifying fibroma, fibrous cortical defect), we studied 72 patients with more than one lesion. Age, sex, coexistent conditions such as neurofibromatosis, and histologic and radiographic appearance of the lesions were evaluated. Multiple skeletal fibroxanthomas are probably more common than previously suspected. (At least 8% of the 900 patients in our archives had multiple lesions). Only a small percentage (5%) of patients with multiple skeletal fibroxanthomas had coexistent neurofibromatosis. These lesions are histologically indistinguishable from their solitary counterparts and most commonly present in the lower extremities. Four radiographic patterns were noted: (1) clustered lesions-usually about the knee. (2) nonclustered lesions-in opposite ends of long bones. (3) coalescent lesions-several lesions coalescing over time. This observation has not been previously reported. (4) emergent lesions-lesions appearing in previously unaffected bone. Familiarity with these features may obviate biopsy.