Michiel Eyselbergs

Pseudotumoural soft tissue lesions of the hand and wrist: a pictorial review

Mimickers of soft tissue tumours in the hand and wrist are more frequent than true neoplastic lesions. Pseudotumours belong to a large and heterogeneous group of disorders, varying from normal anatomical variants, cystic lesions, post-traumatic lesions, skin lesions, inflammatory and infectious lesions, non-neoplastic vascular lesions, metabolic disorders (crystal deposition disease and amyloidosis) and miscellaneous disorders. Although the imaging approach to pseudotumoural lesions is often very similar to the approach to “true” soft tissue tumoral counterparts, further management of these lesions is different. Biopsy should be performed only in doubtful cases, when the diagnosis is unclear. Therefore, the radiologist plays a pivotal role in the diagnosis of these lesions. Awareness of the normal anatomy and existence and common imaging presentation of these diseases, in combination with relevant clinical findings (clinical history, age, location and skin changes), enables the radiologist to make the correct diagnosis in most cases, thereby limiting the need for invasive procedures.

Bone Marrow Changes in Acute and Chronic Trauma

This chapter will discuss the value of medical imaging in the detection and follow-up of bone marrow edema (BME), resulting from acute and chronic trauma. The mechanisms of trauma, clinical significance and natural evolution are emphasized. Unlike plain radiography and computed tomography (CT), magnetic resonance imaging (MRI) is the only imaging technique that allows direct detection of BME. The use of fluid-sensitive sequences is particularly appropriate to evaluate BME. Apart from detection, analysis of the extent of BME may reveal the underlying mechanism of trauma. Following a single acute trauma, compressive forces between two bony structures may result in extensive areas of BME, whereas distraction forces provoke more subtle areas of BME at the insertion of supporting structures of joints. In most clinical situations, a combination of compression and distraction forces is present, causing a complex pattern of BME. A meticulous pattern approach of the distribution of these bone marrow changes around a joint can reveal in most instances the underlying mechanism of trauma. This may be helpful to analyze which joint supporting structures may be at risk. In the acute setting, plain radiography and CT may have an additional role in the detection of small avulsion fractures occurring at the site of minor areas of BME. Apart from an acute traumatic cause, BME may result from repetitive or chronic trauma. This group of lesions comprises stress fractures, chronic avulsive lesions and lesions due to altered biomechanics in certain sports activities. The clinical significance and natural history of BME is still a matter of debate.

“Spinal degeneration: beyond degenerative disc disease”: how to discriminate degeneration from spondylarthropathies?

1. To review the basic anatomy of the vertebral enthesis and sacroiliac joints. 2. To discuss the pathogenesis and plain radiographic features of inflammatory and degenerative disorders (DISH; osteitis condensans ilii) of the sacroiliac joints and spine. 3. To discuss the value of MRI in the early diagnosis of vertebral osteitis, prior to the appearance of structural changes on plain radiographs. 4. To discuss the sensitivity and specificity of spinal inflammatory lesions assessed by MRI in patients with ankylosing spondylitis. Seronegative spondylarthropathy

An unusual cause of bone marrow oedema in the acetabulum

A 37-year-old male with no significant past medicalhistory presented at the orthopaedic surgery departmentwithgraduallyincreasingpaininthelefthipfor3months.3 days prior to presentation the pain exacerbated acutely.There was absence of any previous history of trauma.Clinical examination revealed an antalgic gait andreduced range of motion of the left hip but no signs ofinflammation. The patient’s laboratory results were allwithin normal limits. Bone scintigraphy using

A rare cause of mastitis: Idiopathic Granulomatous Mastitis

A 26-year-old female patient was referred by her gynecologist to the radiology department for evaluation of the right breast. The patient did not have a relevant medical (gynecological) history. During the last five months, she suffered from recurrent breast abscesses. She was treated several times with broad-spectrum antibiotics and surgical drainage, but without clinical improvement. Physical examination revealed a very tender, inflamed breast during palpation. Routine blood tests were normal. Ultrasonography of the right breast demonstrated a large heterogeneous echoic mass (Figure A). Although not shown in the figure, peripheral hypervascularity and a fistula to the skin in the medial retroareolar region were seen. In addition, multiple smaller collections were seen throughout the right breast. The overlying skin was thickened, and several enlarged axillary lymph nodes were present. Subsequent contrast-enhanced magnetic resonance imaging (MRI) confirmed multiple peripheral-enhancing collections (Figure B1) with diffusion restriction (Figure B2) and corresponding low ADC values (Figure B3) in the right breast. Also, global asymmetric enhancement of the right breast tissue and overlying skin compared to the left side was observed (Figure B1). To exclude an underlying carcinoma, a breast biopsy was performed. Malignancy was definitely excluded, but histopathological examination (Figure C) revealed a chronic inflammatory lymphocytic infiltrate (arrow) interspersed with histiocytes (arrowhead) and giant cells (double arrow). No specific aetiological factor could be detected clinically. The patient was treated with corticosteroids, with definite clinical improvement. Based on the clinical history, the imaging features, the histopathology, and good therapeutic response to corticosteroids, the diagnosis of idiopathic granulomatous mastitis (IGM) was made. IGM is a very rare chronic inflammatory breast disease. The etiology has not yet been fully elucidated but may be due to an autoimmune process, infection, a chemical Figure A.

Amiodarone induced pulmonary toxicity mimicking malignancy at initial presentation

An 81-year-old man with an extensive cardiac history was admitted to the cardiology department because of increasing shortness of breath. His medical history included melanoma and prostate adenocarcinoma 7 and 4 years ago respectively. His medication consisted of antihypertensive, anticoagulant and anti-arrhytmic drugs. Non-enhanced computed tomography (CT) of the chest revealed bilateral zones of consolidation (arrowheads) and multiple nodules of varying size (arrows) with predominant localization in the lower lobes (Fig. A). The lowest axial slices through the liver showed an increased attenuation of the liver parenchyma suggestive of amiodarone-induced liver disease (Fig. C(1), ROI: 78 HU). In view of his oncological history the multiple nodular lesions were primarily suspicious for metastasis. Combined pulmonary and liver imaging findings also raised the possibility of amiodarone induced pulmonary toxicity (AIPT). The patient – however – refused further diagnostic testing. Therefore await-and-see policy was implemented and amiodarone was withdrawn. Followup CT of the chest 4 months later showed marked regression of the lesions (Fig. B) and a decreased attenuation of the liver parenchyma confirming the diagnosis of AIPT (Fig. C(2), ROI: 56 HU).

Celiac artery compression syndrome

A 41-year-old woman was referred to our institution for evaluation of recurrent cramping pain in the epigastrium since a couple of months.