Are dilution, slow injection and care bolus technique the causal solution to mitigating arterial-phase artifacts on gadoxetic acid-enhanced MRI? A large-cohort study

OBJECTIVE

Arterial-phase artifacts are gadoxetic acid (GA)-enhanced MRI's major drawback, ranging from 5 to 39%. We evaluate the effect of dilution and slow injection of GA using automated fluoroscopic triggering on liver MRI arterial-phase (AP) acquisition timing, artifact frequency, and lesion visibility.

METHODS AND MATERIALS

Saline-diluted 1:1 GA was injected at 1 ml/s into 1413 patients for 3 T liver MRI. Initially, one senior abdominal radiologist, i.e., principal investigator (PI), assessed all MR exams and compared them to previous and follow-up images, as well as the radiology report on record, determining the standard of reference for lesion detection and characterization. Then, three other readers independently evaluated the AP images for artifact type (truncation (TA), transient severe motion (TSM) or mixed), artifact severity (on a 5-point scale), acquisition timing (on a 4-point scale) and visibility (on a 5-point scale) of hypervascular lesions ≥ 5 mm, selected by the PI. Artifact score ≥ 4 and artifact score ≤ 3 were considered significant and non-significant artifacts, respectively.

RESULTS

Of the 1413 exams, diagnostic-quality arterial-phase images included 1100 (77.8%) without artifacts, 220 (15.6%) with minimal, and 77 (5.4%) with moderate artifacts. Only 16 exams (1.1%) had significant artifacts, 13 (0.9%) with severe artifacts (score 4), and three (0.2%) non-diagnostic artifacts (score 5). AP acquisition timing was optimal in 1369 (96.8%) exams. Of the 449 AP hypervascular lesions, 432 (96.2%) were detected.

CONCLUSION

Combined dilution and slow injection of GA with MR results in well-timed arterial-phase images in 96.8% and a reduction of exams with significant artifacts to 1.1%.

CLINICAL RELEVANCE STATEMENT

Hypervascular lesions, in particular HCC detection, hinge on arterial-phase hyperenhancement, making well-timed, artifact-free arterial-phase images a prerequisite for accurate diagnosis. Saline dilution 1:1, slow injection (1 ml/s), and automated bolus triggering reduce artifacts and optimize acquisition timing.

KEY POINTS

• There was substantial agreement among the three readers regarding the presence and type of arterial-phase (AP) artifacts, acquisition timing, and lesion visibility. • Impaired AP hypervascular lesion visibility occurred in 17 (3.8%) cases; in eight lesions due to mistiming and in nine lesions due to significant artifacts. • When AP timing was suboptimal, it was too late in 40 exams (3%) and too early in 4 exams (0.2%) of exams.

Diagnosis of functional strictures in patients with primary sclerosing cholangitis using hepatobiliary contrast-enhanced MRI: a proof-of-concept study

OBJECTIVES

PSC strictures are routinely diagnosed on T2-MRCP as dominant- (DS) or high-grade stricture (HGS). However, high inter-observer variability limits their utility. We introduce the "potential functional stricture" (PFS) on T1-weighted hepatobiliary-phase images of gadoxetic acid-enhanced MR cholangiography (T1-MRC) to assess inter-reader agreement on diagnosis, location, and prognostic value of PFS on T1-MRC vs. DS or HGS on T2-MRCP in PSC patients, using ERCP as the gold standard.

METHODS

Six blinded readers independently reviewed 129 MRIs to diagnose and locate stricture, if present. DS/HGS was determined on T2-MRCP. On T1-MRC, PFS was diagnosed if no GA excretion was seen in the CBD, hilum or distal RHD, or LHD. If excretion was normal, "no functional stricture" (NFS) was diagnosed. T1-MRC diagnoses (NFS = 87; PFS = 42) were correlated with ERCP, clinical scores, labs, splenic volume, and clinical events. Statistical analyses included Kaplan-Meier curves and Cox regression.

RESULTS

Interobserver agreement was almost perfect for NFS vs. PFS diagnosis, but fair to moderate for DS and HGS. Forty-four ERCPs in 129 patients (34.1%) were performed, 39 in PFS (92.9%), and, due to clinical suspicion, five in NFS (5.7%) patients. PFS and NFS diagnoses had 100% PPV and 100% NPV, respectively. Labs and clinical scores were significantly worse for PFS vs. NFS. PFS patients underwent more diagnostic and therapeutic ERCPs, experienced more clinical events, and reached significantly more endpoints (p < 0.001) than those with NFS. Multivariate analysis identified PFS as an independent risk factor for liver-related events.

CONCLUSION

T1-MRC was superior to T2-MRCP for stricture diagnosis, stricture location, and prognostication.

CLINICAL RELEVANCE STATEMENT

Because half of PSC patients will develop clinically-relevant strictures over the course of the disease, earlier more confident diagnosis and correct localization of functional stricture on gadoxetic acid-enhanced MRI may optimize management and improve prognostication.

KEY POINTS

• There is no consensus regarding biliary stricture imaging features in PSC that have clinical relevance. • Twenty-minute T1-weighted MRC images correctly classified PSC patients with potential (PFS) vs with no functional stricture (NFS). • T1-MRC diagnoses may reduce the burden of diagnostic ERCPs.

Correlation of histologic, imaging, and artificial intelligence features in NAFLD patients, derived from Gd-EOB-DTPA-enhanced MRI: a proof-of-concept study

OBJECTIVE

To compare unsupervised deep clustering (UDC) to fat fraction (FF) and relative liver enhancement (RLE) on Gd-EOB-DTPA-enhanced MRI to distinguish simple steatosis from non-alcoholic steatohepatitis (NASH), using histology as the gold standard.

MATERIALS AND METHODS

A derivation group of 46 non-alcoholic fatty liver disease (NAFLD) patients underwent 3-T MRI. Histology assessed steatosis, inflammation, ballooning, and fibrosis. UDC was trained to group different texture patterns from MR data into 10 distinct clusters per sequence on unenhanced T1- and Gd-EOB-DTPA-enhanced T1-weighted hepatobiliary phase (T1-Gd-EOB-DTPA-HBP), then on T1 in- and opposed-phase images. RLE and FF were quantified on identical sequences. Differences of these parameters between NASH and simple steatosis were evaluated with χ2- and t-tests, respectively. Linear regression and Random Forest classifier were performed to identify associations between histological NAFLD features, RLE, FF, and UDC patterns, and then determine predictors able to distinguish simple steatosis from NASH. ROC curves assessed diagnostic performance of UDC, RLE, and FF. Finally, we tested these parameters on 30 validation cohorts.

RESULTS

For the derivation group, UDC-derived features from unenhanced and T1-Gd-EOB-DTPA-HBP, plus from T1 in- and opposed-phase, distinguished NASH from simple steatosis (p ≤ 0.001 and p = 0.02, respectively) with 85% and 80% accuracy, respectively, while RLE and FF distinguished NASH from simple steatosis (p ≤ 0.001 and p = 0.004, respectively), with 83% and 78% accuracy, respectively. On multivariate regression analysis, RLE and FF correlated only with fibrosis (p = 0.040) and steatosis (p ≤ 0.001), respectively. Conversely, UDC features, using Random Forest classifier predictors, correlated with all histologic NAFLD components. The validation group confirmed these results for both approaches.

CONCLUSION

UDC, RLE, and FF could independently separate NASH from simple steatosis. UDC may predict all histologic NAFLD components.

CLINICAL RELEVANCE STATEMENT

Using gadoxetic acid-enhanced MR, fat fraction (FF > 5%) can diagnose NAFLD, and relative liver enhancement can distinguish NASH from simple steatosis. Adding AI may let us non-invasively estimate the histologic components, i.e., fat, ballooning, inflammation, and fibrosis, the latter the main prognosticator.

KEY POINTS

• Unsupervised deep clustering (UDC) and MR-based parameters (FF and RLE) could independently distinguish simple steatosis from NASH in the derivation group. • On multivariate analysis, RLE could predict only fibrosis, and FF could predict only steatosis; however, UDC could predict all histologic NAFLD components in the derivation group. • The validation cohort confirmed the findings for the derivation group.

Validation of the TNM-8 AJCC classification for HPV-positive oropharyngeal cancers in patients undergoing trans-oral robotic surgery

High-risk human papillomaviruses (HPV) are associated with some oropharyngeal squamous cell carcinomas (OPSCC). HPV-OPSCC have better survival outcomes compared to HPV negative tumours. The new TNM-8 AJCC staging (2018) is based on ICON-S data with 98% of patients treated with primary chemoradiation. To validate the TNM-8 AJCC classification in HPV-OPSCC treated primarily with surgery (trans-oral robotic surgery or open). There were 102 patients with HPV-OPSCC treated between July 2009 and December 2014 at the Royal Adelaide Hospital. The median age was 57 years (range: 38-83) and mostly males (84.5%). 27.2% were active smokers and 50.5% reformed smokers. Early T-stage cancer in 72.8%. Primary treatment was surgery & adjuvant therapy (70%) while primary chemoradiation (30%). Survival analyses were performed for the 7th and 8th AJCC systems. The reclassification to the AJCC 8th edition staging system resulted in a change of 54 patients from stage 4 to stages 1 and 2. This was mainly an effect of changes with N2a and N2b nodal disease being reclassified to N1. Survival outcomes were comparable with the ICON-S data. The new TNM-8 classification is, therefore, validated in a cohort treated, predominantly, with primary surgery and adjuvant therapy.

Influence of dilution on arterial-phase artifacts and signal intensity on gadoxetic acid-enhanced liver MRI

OBJECTIVES

To investigate the effect of saline-diluted gadoxetic acid, done for arterial-phase (AP) artifact reduction, on signal intensity (SI), and hence focal lesion conspicuity on MR imaging.

METHODS

We retrospectively examined 112 patients who each had at least two serial gadoxetic acid-enhanced liver MRIs performed at 1 ml/s, first with non-diluted (ND), then with 1:1 saline-diluted (D) contrast. Two blinded readers independently analyzed the artifacts and graded dynamic images using a 5-point scale. The absolute SI of liver parenchyma, focal liver lesions (if present), aorta, and portal vein at the level of the celiac trunk and the SI of the paraspinal muscle were measured in all phases. The signal-to-norm (SI_Norm) of the vascular structures, hepatic parenchyma and focal lesions, and the contrast-to-norm (C_Norm) of focal liver lesions were calculated.

RESULTS

AP artifacts were significantly reduced with dilution. Mean absolute contrast-enhanced liver SI was significantly higher on the D exams compared to the ND exams. Likewise, SI_Norm of liver parenchyma was significantly higher in all contrast-enhanced phases except transitional phase on the D exams. SI_Norm values in the AP for the aorta and in the PVP for portal vein were significantly higher on the diluted exams. The C_Norm was not significantly different between ND and D exams for lesions in any imaging phase. The interclass correlation coefficient was excellent (0.89).

CONCLUSION

Gadoxetic acid dilution injected at 1ml/s produces images with significantly fewer AP artifacts but no significant loss in SI_Norm or C_Norm compared to standard non-diluted images.

KEY POINTS

• Diluted gadoxetic acid at slow injection (1 ml/s) yielded images with higher SI_Norm of the liver parenchyma and preserved C_Norm for focal liver lesions. • Gadoxetic acid-enhanced MRI injected at 1 ml/s is associated with arterial-phase (AP) artifacts in 31% of exams, which may degrade image quality and limits focal liver lesion detection. • Saline dilution of gadoxetic acid 1:1 combined with a slow injection rate of 1 ml/s significantly reduced AP artifacts from 31 to 9% and non-diagnostic AP artifacts from 16 to 1%.

Modern imaging of cholangitis

Cholangitis refers to inflammation of the bile ducts with or without accompanying infection. When intermittent or persistent inflammation lasts 6 months or more, the condition is classified as chronic cholangitis. Otherwise, it is considered an acute cholangitis. Cholangitis can also be classified according to the inciting agent, e.g. complete mechanical obstruction, which is the leading cause of acute cholangitis, longstanding partial mechanical blockage, or immune-mediated bile duct damage that results in chronic cholangitis.The work-up for cholangitis is based upon medical history, clinical presentation, and initial laboratory tests. Whereas ultrasound is the first-line imaging modality used to identify bile duct dilatation in patients with colicky abdominal pain, cross-sectional imaging is preferable when symptoms cannot be primarily localised to the hepatobiliary system. CT is very useful in oncologic, trauma, or postoperative patients. Otherwise, magnetic resonance cholangiopancreatography is the method of choice to diagnose acute and chronic biliary disorders, providing an excellent anatomic overview and, if gadoxetic acid is injected, simultaneously delivering morphological and functional information about the hepatobiliary system. If brush cytology, biopsy, assessment of the prepapillary common bile duct, stricture dilatation, or stenting is necessary, then endoscopic ultrasound and/or retrograde cholangiography are performed. Finally, when the pathologic duct is inaccessible from the duodenum or stomach, percutaneous transhepatic cholangiography is an option. The pace of the work-up depends upon the severity of cholestasis on presentation. Whereas sepsis, hypotension, and/or Charcot's triad warrant immediate investigation and management, chronic cholestasis can be electively evaluated.This overview article will cover the common cholangitides, emphasising our clinical experience with the chronic cholestatic liver diseases.

Volumetric MRI analysis of Multilevel Upper Airway Surgery effects on pharyngeal structure

STUDY OBJECTIVES

The Sleep Apnea Multilevel Surgery (SAMS) trial found that modified uvulopalatopharyngoplasty with tonsillectomy (if tonsils present) combined with radiofrequency tongue ablation reduced obstructive sleep apnea (OSA) severity and daytime sleepiness in moderate-severe OSA. This study aimed to investigate mechanisms of effect on Apnoea-Hypopnoea Index (AHI) reduction by assessing changes in upper airway volumes (airway space, soft palate, tongue, and intra-tongue fat).

METHODS

This is a case series analysis of forty-three participants of 51 randomized to the surgical arm of SAMS trial who underwent repeat magnetic resonance imaging (MRI). Upper airway volume, length, and cross-sectional area, soft palate and tongue volumes and tongue fat were measured. Relationships between changes in anatomical structures and apnea-hypopnea index (AHI) were assessed.

RESULTS

The participant sample was predominantly male (79%); mean ± SD age 42.7 ± 13.3 years, body mass index 30.8 ± 4.1 kg.m 2, and AHI 47.0 ± 22.3 events/hour. There were no, or minor, overall volumetric changes in the airway, soft palate, total tongue, or tongue fat volume. Post-surgery there was an increase in the minimum cross-sectional area by 0.1 cm 2 (95% confidence interval 0.04-0.2cm 2) in the pharyngeal airway, but not statistically significant on corrected analysis. There was no association with anatomical changes and AHI improvement.

CONCLUSIONS

This contemporary multi-level upper airway surgery has been shown to be an effective OSA treatment. The current anatomical investigation suggests there are not significant post-operative volumetric changes associated with OSA improvement six-months post-surgery. This suggests that effect on OSA improvement is achieved without notable deformation of airway volume. Reduced need for neuromuscular compensation during wake following anatomical improvement via surgery could explain lack of measurable volume change. Further research to understand the mechanisms of action of multilevel surgery is required.

Imaging of inflammatory disease of the pancreas

Increasingly acute and chronic pancreatitis (AP and CP) are considered a continuum of a single entity. Nonetheless, if, after flare-up, the pancreas shows no residual inflammation, it is classified as AP. CP is characterised by a long cycle of worsening and waning glandular inflammation without the pancreas ever returning to its baseline structure or function. According to the International Consensus Guidelines on Early Chronic Pancreatitis, pancreatic inflammation must last at least 6 months before it can be labelled CP. The distinction is important because, unlike AP, CP can destroy endocrine and exocrine pancreatic function, emphasising the importance of early diagnosis. As typical AP can be diagnosed by clinical symptoms plus laboratory tests, imaging is usually reserved for those with recurrent, complicated or CP. Imaging typically starts with ultrasound and more frequently with contrast-enhanced computed tomography (CECT). MRI and/or MR cholangiopancreatography can be used as a problem-solving tool to confirm indirect signs of pancreatic mass, differentiate between solid and cystic lesions, and to exclude pancreatic duct anomalies, as may occur with recurrent AP, or to visualise early signs of CP. MR cholangiopancreatography has replaced diagnostic endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP, and/or endoscopic ultrasound (EUS) remain necessary for transpapillary biliary or pancreatic duct stenting and transgastric cystic fluid drainage or pancreatic tissue sampling, respectively. Finally, positron emission tomography-MRI or positron emission tomography-CT are usually reserved for complicated cases and/or to search for extra pancreatic systemic manifestations. In this article, we discuss a broad spectrum of inflammatory pancreatic disorders and the utility of various modalities in diagnosing acute and chronic pancreatitis.

Cross validated serum small extracellular vesicle microRNAs for the detection of oropharyngeal squamous cell carcinoma

BACKGROUND

Oropharyngeal squamous cell carcinoma (OPSCC) is often diagnosed at an advanced stage because the disease often causes minimal symptoms other than metastasis to neck lymph nodes. Better tools are required to assist with the early detection of OPSCC. MicroRNAs (miRNAs, miRs) are potential biomarkers for early head and neck squamous cell cancer diagnosis, prognosis, recurrence, and presence of metastatic disease. However, there is no widespread agreement on a panel of miRNAs with clinically meaningful utility for head and neck squamous cell cancers. This could be due to variations in the collection, storage, pre-processing, and isolation of RNA, but several reports have indicated that the selection and reproducibility of biomarkers has been widely affected by the methods used for data analysis. The primary analysis issues appear to be model overfitting and the incorrect application of statistical techniques. The purpose of this study was to develop a robust statistical approach to identify a miRNA signature that can distinguish controls and patients with inflammatory disease from patients with human papilloma virus positive (HPV +) OPSCC.

METHODS

Small extracellular vesicles were harvested from the serum of 20 control patients, 20 patients with gastroesophageal reflux disease (GORD), and 40 patients with locally advanced HPV + OPSCC. MicroRNAs were purified, and expression profiled on OpenArray™. A novel cross validation method, using lasso regression, was developed to stabilise selection of miRNAs for inclusion in a prediction model. The method, named StaVarSel (for Stable Variable Selection), was used to derive a diagnostic biomarker signature.

RESULTS

A standard cross validation approach was unable to produce a biomarker signature with good cross validated predictive capacity. In contrast, StaVarSel produced a regression model containing 11 miRNA ratios with potential clinical utility. Sample permutations indicated that the estimated cross validated prediction accuracy of the 11-miR-ratio model was not due to chance alone.

CONCLUSIONS

We developed a novel method, StaVarSel, that was able to identify a panel of miRNAs, present in small extracellular vesicles derived from blood serum, that robustly cross validated as a biomarker for the detection of HPV + OPSCC. This approach could be used to derive diagnostic biomarkers of other head and neck cancers.

Transoral robotic narrow field oropharyngectomy for tumours of the parapharyngeal space

The advent of transoral robotic surgery (TORS) has allowed transoral approaches for parapharyngeal space (PPS) tumours to be re-evaluated. It provides enhanced visualisation and instrument access for appropriate tumours. We describe a specific technique, TORS narrow-field oropharyngectomy, that is ideal for benign PPS tumours which have been violated by intra-oral biopsy or incision and drainage. This allows the contaminated, overlying oropharyngeal mucosa to be resected en-bloc with the PPS tumour, reducing the risk of local recurrence. This technique provides a window into the PPS, improving visualisation of underlying neurovascular structures as well as the tumour. This reduces the risk of tumour spillage and leads to superior vascular access and haemorrhage control. This technique is only applicable to PPS tumours that are appropriate for transoral approaches and is specifically designed for those selected patients that have been placed at risk of seeding or local scarring by intra-oral procedures prior to definitive resection. We present two such cases: a 38-year-old male with a PPS inflammatory cyst and a 66-year-old female with a PSS pre-styloid Schwannoma.

Inter- and intra-reader agreement for gadoxetic acid-enhanced MRI parameter readings in patients with chronic liver diseases

Objectives

To examine inter- and intra-observer agreement for four simple hepatobiliary phase (HBP)–based scores on gadoxetic acid (GA)–enhanced MRI and their correlation with liver function in patients with mixed chronic liver disease (CLD).

Methods

This single-center, retrospective study included 287 patients (62% male, 38% female, mean age 53.5 ± 13.7 years) with mixed CLD (20.9% hepatitis C, 19.2% alcoholic liver disease, 8% hepatitis B) who underwent GA-enhanced MRI of the liver for clinical care between 2010 and 2015. Relative liver enhancement (RLE), contrast uptake index (CUI), hepatic uptake index (HUI), and liver-to-spleen contrast index (LSI) were calculated by two radiologists independently using unenhanced and GA-enhanced HPB (obtained 20 min after GA administration) images; 50 patients selected at random were reviewed twice by one reader to assess intra-observer reliability. Agreement was assessed by intraclass correlation coefficient (ICC). The albumin-bilirubin (ALBI) score, the model of end-stage liver disease (MELD), and the Child-Turcotte-Pugh (CTP) score were calculated as standards of reference for hepatic function.

Results

Intra-observer ICCs ranged from 0.814 (0.668–0.896) for CUI to 0.969 (0.945–0.983) for RLE. Inter-observer ICCs ranged from 0.777 (0.605–0.874) for HUI to 0.979 (0.963–0.988) for RLE. All HBP-based scores correlated significantly (all p < 0.001) with the ALBI, MELD, and CTP scores and were able to discriminate patients with a MELD score ≥ 15 versus ≤ 14, with area under the curve values ranging from 0.760 for RLE to 0.782 for HUI.

Conclusion

GA-enhanced, MRI-derived, HBP-based parameters showed excellent inter- and intra-observer agreement. All HBP-based parameters correlated with clinical and laboratory scores of hepatic dysfunction, with no significant differences between each other.

Key Points

• Radiological parameters that quantify the hepatic uptake of gadoxetic acid are highly reproducible.

• These parameters can be used interchangeably because they correlate with each other and with scores of hepatic dysfunction.

• Assessment of these parameters may be helpful in monitoring disease progression.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06182-z) contains supplementary material, which is available to authorized users.

How I do it: transnasal retraction during transoral robotic oropharyngeal resection

Collapse of the resection plane presents a frustrating problem during transoral robotic resection, in a situation already typified by limited vision and access for instruments. We present a quick and cost-effective retraction technique to effectively mitigate this issue and increase the ease and reliability of robotic oropharyngeal resection. This technique utilises a simple transnasal apparatus to create greater exposure of the resection plane. A Y-suction catheter is inserted into the oropharynx via the nasal cavity. A silk suture is then used to attach it to the oropharyngeal resection specimen. When pulled from the nasal cavity, this apparatus adds a non-intrusive, tremor-free fixation point that pulls the resected specimen along a unique cephalo-posterior vector. This significantly improves access and vision of the desired dissection plane. The entire process takes approximately 1-2 min per side to properly execute. It can be adapted for various pathologies and subsites of the oropharynx. This transnasal technique is a simple, minimally invasive, and inexpensive method for improving wound tension during transoral oropharyngeal resection.

The Efficacy of MRI in the diagnostic workup of cystic fibrosis-associated liver disease: A clinical observational cohort study

PURPOSE

To identify independent imaging features and establish a diagnostic algorithm for diagnosis of cystic fibrosis (CF)-associated liver disease (CFLD) in CF patients compared to controls using gadoxetic acid-enhanced MRI.

METHODS

A total of 90 adult patients were enrolled: 50 with CF, 40 controls. The CF group was composed of two subgroups: a retrospective test subgroup (n = 33) and a prospective validation subgroup (n = 17). Controls (patients with normal liver enzymes and only benign focal liver lesions) were divided accordingly (27:13). MRI variables, including quantitative and qualitative parameters, were used to distinguish CFLD from controls using clinical symptoms, laboratory tests and Debray criteria. Disease severity was classified according to Child-Pugh and Albumin-Bilirubin (ALBI) scores. Fifteen qualitative single-lesion CF descriptors were defined. Two readers independently evaluated the images. Univariate statistical analysis was performed to obtain significant imaging features that differentiate CF patients from controls. Through multivariate analysis using chi-squared automatic interaction detector (CHAID) methodology the most important descriptors were identified. Diagnostic performance was assessed by receiver-operating characteristic (ROC) analysis.

RESULTS

Three independent imaging descriptors distinguished CFLD from controls: (1) presence of altered gallbladder morphology; (2) periportal tracking; and (3) periportal fat deposition. Prospective validation of the classification algorithm demonstrated a sensitivity of 94.1% and specificity of 84.6% for discriminating CFLD from controls. Disease severity was well associated with the imaging features.

CONCLUSIONS

A short unenhanced MRI protocol can identify the three cardinal imaging features of CFLD. The hepatobiliary phase of gadoxetic acid-enhanced MRI can define CFLD progression.

KEY POINTS

• Using a multivariate classification analysis, we identified three independent imaging features, altered gallbladder morphology (GBAM), periportal tracking (PPT) and periportal fat deposition (PPFD), that could diagnose CFLD with high sensitivity, 94.1 % (95% CI: 71.3-99.9) and moderate specificity, 84.6 % (95% CI: 54.6-98.1). • Based upon the results of this study, gadoxetic acid-enhanced MRI with DWI is able to diagnose early-stage CFLD, as well as its progression.

The clinical value of secretin-enhanced MRCP in the functional and morphological assessment of pancreatic diseases

Secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) provides a non-invasive way, with which, to evaluate pancreatic duct (PD) anatomy and exocrine pancreatic function. S-MRCP can be added to the routine pancreas MR examination in equivocal cases. Moreover, it can detect subtle PD involvement, allowing diagnosis of early, rather than end-stage, pancreatic diseases. Although S-MRCP is a valuable non-invasive diagnostic method, it is only performed in a few centres due to relative high cost. Furthermore, less familiarity with its indications, the examination technique, and image interpretation also contribute to its limited use. Thus, the purpose of this article is to explain secretin's mechanism of action, the examination technique, the clinically relevant indications, the advantages, and limitations. Finally, we will focus on image analysis and its role in achieving an early and accurate diagnosis of specific pancreatic and PD diseases.

Hepatic gadoxetic acid uptake as a measure of diffuse liver disease: Where are we?

MRI has emerged as the most comprehensive noninvasive diagnostic tool for focal liver lesions and diffuse hepatobiliary disorders. The introduction of hepatobiliary contrast agents, most notably gadoxetic acid (GA), has expanded the role of MRI, particularly in the functional imaging of chronic liver diseases, such as nonalcoholic fatty liver disease (NAFLD). GA-enhanced MRI (GA-MRI) may help to distinguish between the two subgroups of NAFLD, simple steatosis and nonalcoholic steatohepatitis. Furthermore, GA-MRI can be used to stage fibrosis and cirrhosis, predict liver transplant graft survival, and preoperatively estimate the risk of liver failure should major resection be undertaken. The amount of GA uptake can be estimated, using static images, by the relative liver enhancement, hepatic uptake index, and relaxometry of T1-mapping during the hepatobiliary phase. On the contrary, the hepatic extraction fraction and liver perfusion can be measured on dynamic imaging. Importantly, there is currently no clear consensus as to which of these MR-derived parameters is the most suitable for assessing liver dysfunction. This review article aims to describe the current role of GA-enhanced MRI in quantifying liver function, primarily in diffuse hepatobiliary disorders.

LEVEL OF EVIDENCE

3 J. Magn. Reson. Imaging 2017;45:646-659.

Morphologic and Molecular Features of Hepatocellular Adenoma with Gadoxetic Acid-enhanced MR Imaging

PURPOSE

To evaluate the diagnostic performance of imaging features of gadoxetic acid-enhanced magnetic resonance (MR) imaging to differentiate among hepatocellular adenoma (HCA) subtypes by using the histopathologic results of the new immunophenotype and genotype classification and to correlate the enhancement pattern on the hepatobiliary phase (HBP) with the degrees of expression of organic anion transporting polypeptide (OATP1B1/3), multidrug resistance-associated protein 2 (MRP) (MRP2), and MRP 3 (MRP3) transporters.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board, and the requirement for informed consent waived. MR imaging findings of 29 patients with 43 HCAs were assessed by two radiologists independently then compared with the histopathologic analysis as the standard of reference. Receiver operating characteristic curves and Spearman rank correlation coefficient were used to test the diagnostic performance of gadoxetic acid-enhanced MR imaging features, which included the retention or washout at HBP and degree of transporter expression. Interreader agreement was assessed by using the κ statistic with 95% confidence interval.

RESULTS

The area under the curve for the diagnosis of inflammatory HCA was 0.79 (95% confidence interval: 0.64, 0.90); for the steatotic type, it was 0.90 (95% confidence interval: 0.77, 0.97); and for the β-catenin type, it was 0.87 (95% confidence interval: 0.74, 0.95). There were no imaging features that showed a significant statistical correlation for the diagnosis of unclassified HCAs. On immunohistochemical staining, OATP1B1/3 expression was the main determinant for the retention, whereas MRP3 was the key determinant for washout of gadoxetic acid at HBP (P < .001). MRP2 appeared to have no role.

CONCLUSION

Gadoxetic acid-enhanced MR imaging features may suggest the subtype of HCA. The degree of OATP1B1/3 and MRP3 expression correlated statistically with gadoxetic acid retention and washout, respectively, in the HBP.

Phenotype analysis impacts testing strategy in patients with Currarino syndrome

Currarino syndrome (OMIM 175450) presents with sacral, anorectal, and intraspinal anomalies and presacral meningocele or teratoma. Autosomal dominant loss-of-function mutations in the MNX1 gene cause nearly all familial and 30% of sporadic cases. Less frequently, a complex phenotype of Currarino syndrome can be caused by microdeletions of 7q containing MNX1. Here, we report one familial and three sporadic cases of Currarino syndrome. To determine the most efficient genetic testing approach for these patients, we have compared results from MNX1 sequencing, chromosomal microarray, and performed a literature search with analysis of genotype-phenotype correlation. Based on the relationship between the type of mutation (intragenic MNX1 mutations vs 7q microdeletion) and the presence of intellectual disability, growth retardation, facial dysmorphism, and associated malformations, we propose a testing algorithm. Patients with the classic Currarino triad of malformations but normal growth, intellect, and facial appearance should have MNX1 sequencing first, and only in the event of a normal result should the clinician proceed with chromosomal microarray testing. In contrast, if growth delay and/or facial dysmorphy and/or intellectual disability are present, chromosomal microarray should be the first method of choice for genetic testing.

Identification of single gene deletions at 15q13.3: further evidence that CHRNA7 causes the 15q13.3 microdeletion syndrome phenotype

The 15q13.3 microdeletion syndrome (OMIM #612001) is characterized by a wide range of phenotypic features, including intellectual disability, seizures, autism, and psychiatric conditions. This deletion is inherited in approximately 75% of cases and has been found in mildly affected and normal parents, consistent with variable expressivity and incomplete penetrance. The common deletion is approximately 2 Mb and contains several genes; however, the gene(s) responsible for the resulting clinical features have not been clearly defined. Recently, four probands were reported with small deletions including only the CHRNA7 gene. These patients showed a wide range of phenotypic features similar to those associated with the larger 15q13.3 microdeletion. To further correlate genotype and phenotype, we queried our database of >15,000 patients tested in the Mayo Clinic Cytogenetics Laboratory from 2008 to 2011 and identified 19 individuals (10 probands and 9 family members) with isolated heterozygous CHRNA7 gene deletions. All but two infants displayed multiple features consistent with 15q13.3 microdeletion syndrome. We also identified the first de novo deletion confined to CHRNA7 as well as the second known case with homozygous deletion of CHRNA7 only. These results provide further evidence implicating CHRNA7 as the gene responsible for the clinical findings associated with 15q13.3 microdeletion.

Fetal ocular measurements by MRI

OBJECTIVE

To present fetal magnetic resonance imaging (MRI) ocular measurement ranges by gestational age (GA) in normal and growth-restricted fetuses.

METHODS

A total of 298 pregnant women from the 18th to the 39th week of gestation were imaged using MRI. Ocular measurements including binocular distance (BOD), interocular distance (IOD), transverse ocular diameter (OD) and anterior-posterior (AP) OD were measured. The curve estimation analyses for linear, logarithmic and quadratic models were performed. The ocular measurements of the fetuses with intrauterine growth restriction (IUGR) were compared with that of the normal fetuses.

RESULTS

The fetal eye resembles an ellipsoid with significantly longer OD and shorter AP (t = - 22.07, p < 0.001). The quadratic model was the best model in predicting growth of the fetal BOD, IOD, OD and AP. The ocular measurements of the fetuses with IUGR were significantly different from that of the normal fetuses (BOD: t = 3.58, p < 0.001; IOD: t = 5.73, p < 0.001; OD: t = 3.52, p < 0.001; AP: t = 2.19, p < 0.05).

CONCLUSION

Fetal ocular growth can be readily assessed by fetal MRI. Using the normative data provided in this study, fetal ocular anomalies may be detected. Ocular size is frequently reduced in the condition of IUGR, with potential pathologic impact on postnatal vision.

Molecular studies of segmental aneusomy: FISHing for the atypical cry in del(5)(p15.3)

We report a newborn male with multiple congenital anomalies including growth retardation, hypotonia, dysmorphic facies, widely-spaced nipples, micropenis, cryptorchidism, optic nerve hypoplasia, heart disease, and a striking, high-pitched cry. Chromosome analysis revealed de novo partial trisomy 11q due to a der(5)t(5;11)(p15.3;q22). Fluorescence in situ hybridization (FISH) showed loss of the 5p telomere signal on the der(5) chromosome, indicating the infant has partial monosomy 5p in addition to partial trisomy 11q. Among cases involving trisomy 11q, an unusual cry has only been documented in the presence of a der(5)t(5p;11q). This apparent dependence of the abnormal cry on monosomy 5p suggested the same genetic mechanism that occurs in Cri du chat syndrome (CDCS) may be responsible for the atypical cry in der(5)t(5p;11q) individuals. Neither a commercial CDCS probe (LSI D5S23, D5S721) nor a series of BAC clones encompassing distal regions implicated in the CDCS-associated cat-cry were deleted in our patient. These results suggest a second cry-modifying locus maps telomeric to BAC RP11-94J21 in band 5p15.33. This locus may not only cause the abnormal cry in individuals with a der(5)t(5p;11q) but could also contribute to the phenotypic variability and discordant mapping studies observed for CDCS.

Severe myositis ossificans in a paraplegic trauma patient: Influence in pressure sore management

Myositis ossificans (MO) is a benign, progressive, ossifying lesion that displays a characteristic zonal histological appearance. MO traumatica is a localized form of heterotopic bone formation, associated with repetitive micro- and/or macrotrauma in the majority of cases. The importance of imaging to differentiate MO from sarcomatous change and to determine maturity of the lesion is identified because suboptimal operative intervention on immature MO inevitably results in recurrence. A severe case of MO in a 24-year-old paraplegic man with chronic bilateral greater trochanteric pressure sores is presented, and the importance of the MO in the etiology and treatment of this case is discussed. An extensive review of the literature is included and integrated.

A technique for atraumatic clamping of calcified arteries

Images

Cementoplasty and the oncologic population

The first and only description of percutaneous cementoplasty, to date, has been described in the French medical literature in 1994. In this series of 12 cases, radiologists successfully instilled a cement derivative into the acetabulum under fluoroscopic control. As in these cases, the major indication for cementoplasty is to provide pain control and stabilization of an osteolytic lesion. Potential complications include physical or thermal damage to the adjacent neurovascular structures, either during needle positioning or from cement leakage, respectively. Although no absolute contraindications exist, one should proceed cautiously in patients with coagulopathies. Results may be suboptimal as well in patients with pathologic fractures.

The incidence of sacroiliac joint disease in patients with low-back pain

PURPOSE

The clinical presentation of intervertebral disc, facet joint, nerve root, and sacroiliac (SI) joint diseases are often indistinguishable. SI joint arthritis likely accounts for a significant proportion of what is called "low-back pain" or "sciatica." Our goal was to determine the incidence of SI joint arthritis in patients with this presentation.

METHODS

Computed tomographic (CT) scans of the lumbosacral spine (LSS) of patients referred with low-back pain, sciatica, spinal stenosis or disc pathology were gathered over a 3-month period. Scans were retrospectively reviewed by 2 independent readers for SI joint arthritis. When there was disagreement, the 2 readers reviewed the case and reached a concensus opinion. SI joint arthritis was considered to be present if subchondral sclerosis, osteophytosis, or cartilage loss was noted on the CT scan.

RESULTS

The SI joint(s) were visualized by both readers on 64 LSS CT scans performed in 29 women and 35 men, mean age 52 years. By the aforementioned criteria, 16 SI joints (25%) were considered normal by both readers. In 48 cases (75%), there was evidence of osteoarthritis. The diagnosis of osteoarthritis was made by concensus opinion in 8 of these 48 cases (16%).

CONCLUSION

There is a relatively high incidence of SI joint arthritis in patients undergoing evaluation for "low-back pain" or "sciatica." Hence, SI joint arthritis should be considered a possible diagnosis in these patients.

Clinics in diagnostic imaging (42). Shepherd's fracture

A 21-year-old woman presented with severe ankle pain during a soccer match. Radiographs showed a Shepherd's fracture of the talus. She responded well to conservative treatment. The imaging anatomy of the posterior talus and os trigonum is reviewed, together with radiological features of osteochondritis dissecans of the talar dome.

Bilateral radial head and neck fractures

Isolated radial head and neck fractures comprise 1-2% of all fractures seen by physicians. Although bilateral distal radial fractures have been documented, primarily in gymnasts, no literature is present on bilateral radial head or neck fractures. This article presents two such patients who sustained nondisplaced bilateral radial head or neck fractures resulting from falls on outstretched hands. The detection, classification, and treatment options of radial head fractures is reviewed.

Clinics in diagnostic imaging (40). Iliotibial band syndrome

A 51-year-old male cyclist presented with a mass over the lateral portion of his knee. MR scans showed a cystic collection deep to the iliotibial band (ITB). Diagnosis of the ITB syndrome and its differentiation from other cause of painful lateral knee masses, such as meniscal cyst, lateral collateral ligament injury and Segond fracture, are discussed.

Percutaneous biopsy of the musculoskeletal system: a review of 77 cases

OBJECTIVE

To analyze the accuracy of percutaneous bone and soft-tissue biopsies.

METHODS

A total of 77 percutaneous biopsies performed under computed tomographic or fluoroscopic guidance over a 24-month period were reviewed. The biopsies were performed in 74 patients, 32 male and 42 female, with a mean age of 60.3 years.

RESULTS

Sixty-three bone and 14 soft-tissue biopsies were performed. No follow-up information was available for 8 patients, and 1 patient died before an accurate diagnosis could be made. There were 44 true-positive, 17 true-negative, 8 false-negative and no false-positive results. The correct diagnosis was obtained in 57 of 68 cases (83.8%). For bone biopsies, the accurate diagnosis was obtained in 47 of 55 cases (85.5%). For soft-tissue biopsies, the correct diagnosis was obtained in 10 of the 13 cases (76.9%). Diagnostic accuracy was slightly better for osteolytic than for osteosclerotic lesions. Accuracy also varied with lesion site and needle type. Cytology and pathology specimens were almost equally useful in contributing to the correct diagnosis.

CONCLUSION

The accuracy of percutaneous biopsy achieved in this series is similar to that found in other series. Although diagnostic accuracy varied, accuracy is improved if both cytologic and pathologic specimens are analyzed.

Anterior process fracture or calcaneus secundarius: a case report

Avulsion of the anterior process of the calcaneus accounts for nearly 15% of calcaneal fractures according to some sources. Yet, this fracture rarely has been reported in the radiology literature. Lateral plain radiography of the foot may demonstrate an ossific structure, distinct from the distal end of the calcaneus, overlying the head of the talus. However, the fracture may be particularly subtle and go undetected on plain radiography. Furthermore, it may be mistaken for the calcaneus secundarius (CS), an accessory ossicle of the anterior facet of the calcaneus identified in up to 5% of the population during cadaveric studies. This article describes the physical and radiological findings in a patient with an anterior process fracture and how this fracture can be distinguished from the CS.

Diagnosis of the acute os peroneum fracture

Acute fracture of the os peroneum is a relatively uncommon injury. However physicians must be cognizant of its occurrence and include it in their differential diagnosis of acute ankle trauma. A careful clinical evaluation as well as awareness of its radiographic appearance and of the possibility for injury to other surrounding structures is important in the appropriate diagnosis and management of this fracture. We present the case of a patient who sustained an os peroneum fracture and review the relevant literature.

Pisiform and hamulus fractures: easily missed wrist fractures diagnosed on a reverse oblique radiograph

We present a review of the current literature involving fractures of the pisiform and hook of the hamate. This is highlighted by two cases in which the fracture lines are seen only on the reverse oblique wrist radiograph, a view obtained with the wrist in a supinated rather than a pronated position. These fractures are not seen on standard two or three view wrist examination. Both of these fractures were initially missed in the emergency department. Serious sequelae can result from both of these injuries and can be avoided if diagnosed acutely. The reverse oblique radiograph can be quick, cost-effective, and diagnostic in this setting. If properly treated by immobilization or excision, the results can be excellent.

Avulsion fracture of tendon of extensor carpi radialis longus: unknown mechanism

Fractures of the base of the second metacarpal are infrequent events compared with those of the first or fifth metacarpal. Furthermore, these fractures are often difficult to visualize on standard radiographs. There is controversy regarding the management of such fractures. Two case reports and a discussion of this entity are presented.

Clinics in diagnostic imaging (21). Intraosseous lipoma of the calcaneum

A 50-year-old woman presented with plantar foot pain. Radiographs and computed tomography demonstrated an intraosseous lipoma of the calcaneum. Curettage and packing were performed. The imaging features, including the magnetic resonance appearances, of intraosseous lipomas are described.

Osteochondral allografts with an intramedullary muscle flap in rabbits

A model for hemijoint reconstruction using partially demineralized and lyophilized osteochondral allografts combined with an intramedullary muscle flap is described. The proximal 2/3 of the humerus was resected in 10 rabbits. The remaining defect was reconstructed with either a control lyophilized osteochondral allograft or a lyophilized allograft with a muscle flap filling the marrow cavity. Graft healing was followed by serial radiographs and magnetic resonance imaging. The grafts were harvested at 5 weeks for histologic analysis. By 5 weeks, 4 of 5 control allografts had fractured. In contrast, only 1 allograft with an intramedullary muscle flap showed evidence of a cortical break. Magnetic resonance imaging of control allografts showed a persistent large dead space within the marrow cavity and callus formation only at the outer cortical surface. Magnetic resonance imaging of allografts with an intramedullary muscle flap showed muscle obliterating the marrow cavity and areas of callus formation at both the outer and inner cortical surfaces. Histologically, graft incorporation was occurring at the outer cortical surface of the control allografts. In contrast, graft incorporation was occurring at both the outer and inner cortical surfaces of the allografts with an intramedullary muscle flap. The articular surface of the control allografts was severely degenerated. In allografts with an intramedullary muscle flap, the articular surface was smoother. Joints reconstructed with allografts with an intramedullary muscle flap had a significantly better range of motion at 5 weeks compared with control allografts. These results suggest that an intramedullary muscle flap can improve the functional results of joints reconstructed with partially demineralized and lyophilized osteochondral allografts by providing both vascularity and an increased population of mesenchymal stem cells capable of responding to bone morphogenetic proteins that reside in the partially demineralized allograft.

Prevalence of red marrow around the knee joint in adults as demonstrated on magnetic resonance imaging

RATIONALE AND OBJECTIVES

We determined the prevalence of red marrow around the knee joint in adults and evaluated variations with age, gender, and other variables.

METHODS

One hundred ninety-nine adult patients presenting for routine knee magnetic resonance (MR) imaging completed a questionnaire that covered age, gender, menstrual history, past pregnancies, smoking history, and medications. The presence or absence of visible red marrow in the distal femur and proximal tibia on both coronal and sagittal MR images was recorded for each patient. Associations between the presence of red marrow and the other recorded variables then were evaluated.

RESULTS

Red marrow was present in more than half of the women and less than one sixth of the men, a statistically significant difference. The age distribution of red marrow in men and women also was different. Red marrow was the most common in women aged 30-60 years. In men, there was no clear-cut age trend. Red marrow also was more likely to be present in obese individuals and smokers. No association was found between the presence of red marrow and any of the other recorded variables.

CONCLUSION

There are clear gender, age, obesity, and smoking-related differences in the prevalence of red marrow around the knee joint in adults. Red marrow is relatively common in this site in all age groups, and its presence should not be a cause for clinical concern.

Depiction of pelvic fractures using 3D volumetric holography: comparison of plain X-ray and CT

OBJECTIVE

The goal of this study was to demonstrate the feasibility and test the diagnostic performance of a new technology, 3D volumetric holography, for imaging pelvic fractures. The management of pelvic fractures may be complex, and advanced imaging studies such as CT are frequently indicated. Multiplanar CT reformations and 3D renderings provide clinically useful and complementary display of the directly acquired CT data. With the recent availability of volumetric multiple exposure holograms, produced from serial image data, it is now possible to produce true 3D images of the pelvis. In the hologram, one may view the CT data in 3D or as individual planar slices constituting the whole 3D pelvis. The diagnostic performance of the volumetric multiple exposure holograms was tested against routine radiography, CT, and 3D volumetric CT reconstructions.

MATERIALS AND METHODS

Routine radiography and CT were performed in 15 patients with suspected pelvic fractures. Volumetric multiple exposure holograms and 3D volumetric CT reconstructions were created from the CT data. Axial and multiplanar reformation CT images were used as the standard for fracture, diastasis, and intraarticular fragment detection.

RESULTS

Radiograms detected 39 of 50 of the fractures and diastases and no intraarticular fragments. The 3D CT reconstructions and the holograms viewed as 3D objects alone missed two small fractures of the anterior column and one hip with intraarticular bone fragments. When the volumetric multiple exposure holograms were viewed as a 3D object and as individual planar slices constituting the whole, their results were the same as the standard.

CONCLUSION

Volumetric multiple exposure holograms were as sensitive and specific as axial CT and multiplanar reformations in detecting fracture pathology. By containing and making available, from one image, both planar and 3D information, volumetric multiple exposure holograms detected subtle anatomical features that were hidden by overlapping structures in the radiographs and the 3D CT images.

Analysis of carpal instability: II. Clinical applications

An analytic scheme for carpal instability patterns has been described to help standardize reporting of these conditions. Six categories to be recognized in each case are chronicity, constancy, etiology, location, direction, and pattern. Examples are presented to illustrate the use of this scheme.

Analysis of carpal instability: I. Description of the scheme

There is a lack of a generally agreed analysis of carpal instability that can assist in the diagnosis, give guidelines for treatment, and ensure unity when reporting results of treatment. Based on the literature and using six categories describing chronicity, constancy, etiology, location, direction, and pattern of the instability, we present a proposal for a standardized analysis. Using this analysis, an instability should be presented with information in all six categories. The analysis may be expanded and developed according to future needs.

Digitized radiographs in skeletal trauma: a performance comparison between a digital workstation and the original film images

PURPOSE

To evaluate the diagnostic performance of a teleradiology system in skeletal trauma.

MATERIALS AND METHODS

Radiographs from 180 skeletal trauma patients were digitized (matrix, 2,000 x 2,500) and transmitted to a remote digital viewing console (1,200-line monitor). Four radiologists interpreted both the original film images and digital images. Each reader was asked to identify, locate, and characterize fractures and dislocations. Receiver operating characteristic curves were generated, and the results of the original and digitized film readings were compared.

RESULTS

All readers performed better with the original film when interpreting fractures. Although the patterns varied between readers, all had statistically significant differences (P < .01) for the two image types. There was no statistically significant difference in performance with the two images when dislocations were diagnosed.

CONCLUSION

The system tested is not a satisfactory alternative to the original radiograph for routine reading of fracture films.

Recurrent disk versus scar in the postoperative patient: the role of computed tomography (CT)/diskography and CT/myelography

The purpose of this study was to compare computed tomography (CT)/myelography and CT/diskography images, in a given patient, as a method of distinguishing postoperative fibrosis from recurrent herniated disk material. The study population consisted of 20 patients who had undergone lumbar diskectomy and subsequently developed recurrent radicular pain. All patients underwent CT/myelography and CT/diskography, each procedure performed within 72 h of the other. Comparison of transaxial images from CT/myelography and CT/diskography at a given disk space level yielded the following results: in 12 patients the extradural mass seen via CT/myelography corresponded entirely to the contrast-filled disk fragment seen via CT/diskography (recurrent herniated disk); in three patients the extradural mass seen via CT/myelography was larger than the disk fragment seen via CT/diskography (recurrent herniated disk and fibrosis); and in five patients CT/diskography images appeared normal, but CT/myelography showed an extradural mass (fibrosis). Fifteen patients underwent surgical reexploration with the following results: in three of three patients, the suspicion of recurrent herniated disk and fibrosis by radiologic evaluation was confirmed by surgical reexploration; in nine of 12 patients, solely recurrent herniated disk shown by radiologic criteria was similarly confirmed. The remaining five patients presumed to have fibrosis by radiologic criteria were treated nonoperatively.

Calcific tendinitis in the proximal thigh

Calcific tendinitis of the proximal thigh is a benign entity that may cause significant pain. It must be distinguished from chronic or malignant disorders, such as arthritis, infection, and soft tissue/cortical neoplasms. Although it may be self-limited, some patients will benefit from medical intervention. In such cases, we recommend computed tomography-guided percutaneous steroid injection. Herein we describe the clinical and radiographic features of calcific tendinitis of the proximal thigh in 5 patients.