Accuracy of MRI-based Diagnoses for Distal Upper Extremity Soft Tissue Masses

Ganglions in the Hand and Wrist: Advances in 2 Decades

Ganglion cysts represent the most common soft-tissue mass in the hand and wrist. Ganglion cysts are most commonly encountered at the dorsal or volar aspects of the wrist, although cysts may arise from the flexor tendon sheath, interphalangeal joint, and extensor tendons. Intraosseous and intraneural ganglion cysts have also been described. Diagnosis of ganglion cysts relies primarily on history and physical examination. Transillumination and aspiration of masses may be useful adjuncts to diagnosis. Imaging such as radiography and ultrasonography may be indicated to evaluate for associated conditions, such as degenerative joint disease, or to rule out a solid or heterogeneous mass. Advanced imaging such as MRI is generally reserved for patients in whom occult ganglions, intraosseous ganglions, or solid tumors, including sarcoma, remain a concern. Treatment of ganglion cysts includes observation, aspiration or puncture with possible corticosteroid injection, and surgical excision. Nonsurgical management may result in cyst resolution in over 50% of patients. Surgical excision is associated with recurrence rates of 7% to 39%. Advances in surgical techniques have allowed surgeons to conduct arthroscopic ganglion excision, with recurrence rates similar to those of open management. This study highlights the advances in diagnosis, treatment, and outcomes that have taken place over the past 2 decades for this common condition affecting the hand and wrist in the adult population.

MRI Utility in Hand Surgery

Background: Magnetic resonance imaging (MRI) is frequently used in the diagnosis of upper extremity conditions. We hypothesize that the results often do not change treatment. The purpose of the present study was to prospectively assess the extent to which MRI findings alter patient management. Methods: Ten hand surgeons who were ordering an MRI (elbow or distal) completed a standardized questionnaire. Prior to obtaining the MRI, the surgeon recorded their pre-MRI diagnosis and recommended treatment if no MRI could be obtained. Following the MRI, the surgeon recorded their post-MRI diagnosis and ultimate treatment recommendation. Finally, the surgeon answered whether the MRI was helpful, and if so, how it helped guide their treatment. Descriptive statistics were performed. Results: One hundred eighty-seven MRIs were ordered. The most common reasons for ordering an MRI were the evaluation of presumed occult scaphoid fracture, ulnar wrist pain, metacarpophalangeal joint collateral ligament injury, and mass. The surgeon agreed with the radiologist's interpretation of the MRI in 88% of cases. Overall, surgeons found the MRI to be helpful in 92% of cases, and the recommended treatment changed as a result of the MRI findings in 19% (35/187) of patients. Of these 35 patients, 9 had a pre-MRI diagnosis that was concordant with the MRI findings, but the proposed management of the patient changed after the MRI. Conclusions: Hand surgeons infrequently change their treatment plan based on MRI findings. Given the importance of cost-efficient care, indications for use of MRI may need to be re-evaluated.

Diagnostic value of MRI for detecting recurrent soft-tissue sarcoma in a long-term analysis at a multidisciplinary sarcoma center

Background

Soft-tissue sarcomas (STS) are rare tumors of the soft tissue. Recent diagnostic studies on STS mainly dealt with only few cases of STS and did not investigate the post-therapeutic performance of MRI in a routine clinical setting. Therefore, we assessed the long-term diagnostic accuracy of MRI for detecting recurrent STS at a multidisciplinary sarcoma center.

Methods

In all, 1055 postoperative follow-up MRIs of 204 patients were included in the study. MRI follow-up scans were systematically reviewed for diagnostic values (true-positive/−negative and false-positive/−negative results) in detecting recurrences. Pathological reports and follow-up MRIs were set as baseline references.

Results

The median age of the patients was 55.3 ± 18.2 years. Of the patients, 34.8% presented with recurrences. Here, 65 follow-up scans were true positive, 23 false positive, 6 false negative, and 961 true negative. The overall sensitivity and specificity of MRI for detecting recurrences were 92 and 98%, respectively, with an accuracy of 97%. For intramuscular lesions and after surgery alone the sensitivity was higher (95 and 97%, respectively) than for subcutaneous lesions and surgery with additional radiation therapy (83 and 86%, respectively), at similarly high specificities (96–98%). The 6 false-negative results were found in streaky (n = 2) and small ovoid/nodular (n = 4) recurring lesions. The false-positive lesions imitated streaky (n = 14), ovoid/nodular (n = 8), and polycyclic/multilobulated recurring tumors (n = 1). All false-positive results were found in patients in whom the primary tumors were polycyclic/multilobulated in appearance.

Conclusion

MRI shows a high diagnostic accuracy for detecting recurrent STS, with a high sensitivity and specificity. The diagnostic accuracy decreases in subcutaneous lesions and after surgery with radiation therapy, compared to intramuscular lesions and surgery alone. Radiologists should pay particular attention to streaky and small ovoid/nodular recurring lesions and patients with polycyclic/multilobulated primary tumors.

Comparing the Diagnostic Accuracy of Clinical and Radiological Measures in Hand Soft-Tissue Masses

Introduction

Imaging modalities are imperative to aid in diagnosing hand soft-tissue tumors. Limited insight is available into the diagnostic accuracy of history and physical examination in comparison to radiological diagnosis. 

Methods

In this retrospective analysis, data of patients with hand soft-tissue tumors that were surgically treated and diagnosed through biopsy were extracted; taking this as a reference, the sensitivity, specificity and positive and negative predictive values and likelihood ratios of the clinical approach and radiological tools were contrasted against each other. 

Results

Data of a total of 34 patients were revised in this study. With a mean age of 40.1 years, the most common anatomical area of the hand to be affected by the tumors was the index (n = 7, (18.9%); ganglion cysts were the most common tumor (n = 9, 26.5%) and magnetic resonance imaging was the most commonly used imaging modality (n = 24, 70.6%). Clinical diagnosis scored a sensitivity and specificity of 44.4% and 100% in ganglion cysts and 62.5% and 86.2% in giant cell tumors in contrast to the sensitivity and specificity of 66.7% and 100% for ganglion cysts and 50% and 90% for giant cell tumors scored by radiological modalities.

Conclusion

Clinical diagnosis could be non-inferior to radiological diagnosis, yet radiological examination remains a valuable adjunct to clinical examination. Larger scale, prospective studies are required before generalizing our results.

Long-term diagnostic value of MRI in detecting recurrent aggressive fibromatosis at two multidisciplinary sarcoma centers

PURPOSE

To assess the diagnostic accuracy of MRI in detecting recurrent aggressive fibromatosis (AF) during long-term follow-up at two multidisciplinary sarcoma centers.

METHODS

Seventy-nine patients from two sarcoma centers were included in this IRB-approved study and were examined postoperatively using 1.5-T MRI. MRI follow-up scans were reviewed for true-positive/-negative and false-positive/-negative results. Available pathological reports and MRI follow-ups were set as reference.

RESULTS

The median age of the patients was 38.1 ± 15.3 years. Of the patients 27.9 % showed recurrent AF lesions. The most common localizations of AF were the axilla/shoulder (n = 15) and the thigh (n = 11). From 498 postoperative MRI follow-ups, 24 true-positive, 16 false-positive, 6 false-negative, and 452 true-negative MRI follow-ups were identified. The overall sensitivity and specificity for detecting recurrent AF was 80 % and 97 %, respectively. There was no significant difference in the diagnostic accuracy at the two sarcoma centers. All false-negative results were found in small lesions. False-positive results mostly mimicked streaky (n = 10) and small ovoid/nodular (n = 5) lesions. The configuration of recurrent AF was significantly most often fascicular (50 %; p = 0.001-0.005).

CONCLUSION

MRI shows a high long-term diagnostic value in detecting AF recurrences. Nevertheless, radiologists should pay close attention when lesions are small, as they may remain undetected. Although the configuration of recurrent AF is most often fascicular, recurrences may also appear in different shapes.

Intramuscular Ganglion Cyst of the Flexor Hallucis Brevis Secondary to Muscle Tear: A Case Report

In the current study, we present a case of an intramuscular ganglion cyst in the flexor hallucis brevis muscle (FHB) that arose secondary to a muscle tear. Through this study, we propose a possible aetiology for the development of intramuscular ganglionic cysts. A 50-year-old woman presented with acute pain and swelling over the right mid-plantar area after prolonged kneeling for scrubbing floors. Ultrasonography examination performed at 5 days after the onset of symptoms revealed a partial tear of the right FHB. Follow-up evaluations were conducted, with magnetic resonance imaging and ultrasonography, at 24 and 54 days after symptom onset. MRI revealed a ganglion cyst in the mid-portion of the FHB without connection to the adjacent joint capsule or tendon sheath. On the ultrasonography examination at 45 days after onset, at the same location where a tear was seen on the initial examination, an anechoic defect in the mid-portion of the FHB was observed, compatible with a ganglion cyst. Given the favourable natural evolution, no aspiration or surgery were performed. The patient was discharged with minimal symptoms. The results suggest that the intramuscular ganglion cyst can develop following a muscle tear.

Spectrum of MRI features of ganglion and synovial cysts

Ganglion and synovial cysts occur mainly, but not necessarily, in association with osteoarthritis. Presentation varies widely, ranging from small, incidentally detected, asymptomatic lesions to giant ones that might be the source of symptoms, either due to their compressive effect on adjacent structures or due to complications, such as rupture. On magnetic resonance imaging they are typically presented as smooth, well-circumscribed, thin-walled, unilocular, and homogeneously T2-hyperintense lesions. An identifiable thin stalk communicating to the joint space is not infrequent. Nevertheless, depending on their age, anatomic location, and eventual complication, they might have many distinct appearances, including septae and internal debris, which the radiologist must be familiar with in order to accurately differentiate them from worrisome cystic-like lesions. With regard to this diversity, some illustrative cases are presented.