Update in Imaging Evaluation of Bone and Soft Tissue Sarcomas

Guedes, Alex; Oliveira, Marcelo Bragança dos Reis; Melo, Adelina Sanches de; Carmo, Clarissa Canella Moraes do

doi:10.1055/s-0041-1736569

Alex Guedes Address for correspondence Alex Guedes, PhD, Orthopedic Oncology Group, Santa Izabel Hospital, Santa Casa of Misericórdia of Bahia Marechal Floriano Street, 212, apt. 203, Canela, Salvador, BA, 40110-010, Brazil (e-mail: alexguedes2003@yahoo.com.br).

Orthopedic Oncology Group, Santa Izabel Hospital, Santa Casa of Misericórdia of Bahia, Salvador, BA, Brazil

https://orcid.org/0000-0001-7013-7107

Marcelo Bragança dos Reis Oliveira

Trauma-Orthopedics Service, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

https://orcid.org/0000-0003-1986-7002

Adelina Sanches de Melo

Nuclear Medicine Service, Santa Izabel Hospital, Santa Casa of Misericórdia of Bahia, Salvador, BA, Brazil

https://orcid.org/0000-0003-3021-1901

Clarissa Canella Moraes do Carmo

Department of Radiology, Federal Fluminense University, Niterói, RJ, Brazil

https://orcid.org/0000-0003-0086-0214

Address for correspondence Alex Guedes, PhD, Orthopedic Oncology Group, Santa Izabel Hospital, Santa Casa of Misericórdia of Bahia Marechal Floriano Street, 212, apt. 203, Canela, Salvador, BA, 40110-010, Brazil (e-mail: alexguedes2003@yahoo.com.br).

Conflict of Interests

The authors declare that there are no conflicts of interest.

Figures (3)
Tables (2)

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Fig. 1
Male, 29 years old, high-grade sarcoma in the right knee. Sequences in prosthetic density with fat suppression in the sagittal plane before treatment (A) demonstrating heterogeneous lesion in the posterior compartment. Axial dynamic study (B) and color map (C) demonstrating early enhancement in the posterior and superficial part of the lesion with type III TIC (red line in D). Five months after treatment, conventional resonance does not show a significant change in the signal intensity of the lesion (E). However, the axial dynamic study (F) and color map (G) show a change in the enhancement pattern, with type V TIC (red line in H), indicating good response to treatment. Histological analysis showed more than 90% of tumor necrosis.

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Fig. 2
Tissue characterization of soft tissue lesions. Myxoid liposarcoma in the thigh at T1 with contrast suppression after gadolinium administration (A) and ADC map (B) demonstrating ADC = 2.6 × 10³ mm²/s. Nodular fasciitis of the forearm inT1 with contrast suppression after gadolinium administration (C) and ADC map (D) demonstrating ADC = 1.4 × 10³ mm²/s. Non-Hodgkin lymphoma of the forearm at T1 with contrast suppression after gadolinium administration (E) and ADC (F) map demonstrating ADC = 0.6 × 10³ mm²/s. Leiomyosarcoma of the arm on T1-day with contrast suppression after gadolinium administration (C) and ADC map (D) demonstrating ADC = 0.97 × 10³ mm²/s.

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Fig. 3
Different applicability of magnetic susceptibility sequences (SWI). Undifferentiated sarcoma of the left thigh in prosthetic density with suppression of fat in the axial plane (A) and axial SWI (B) demonstrating hemorrhagic foci inside the lesion. Melanoma metastasis in the right forearm in prosthetic density with coronal (C) and axial SWI (D) fat suppression, demonstrating areas of melanin inside the tumor. Ossifying myositis of the left knee in prosthetic density with fat suppression in the sagittal (E) and axial SWI (F) planes demonstrating peripheral calcification.

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Table 1
Imaging methodologies used in the local evaluation of musculoskeletal sarcomas. Advantages and disadvantages.

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Table 2
Imaging methodologies used in the systemic evaluation of musculoskeletal sarcomas. Advantages and disadvantages

Mode

Advantages

Disadvantages

Conventional radiographs

• Accessible and available;

• Basis of image evaluation - screening for other methodologies;

• Provides the entire anatomical image of the region of interest;

• Superior spatial resolution of the bone trabeculate;

• Bone sarcomas: size, shape and biological behavior;

• Soft tissue sarcomas: mineralization, density and bone involvement;

• Definitive diagnosis in 80% of bone tumors.

• Limited evaluation of soft tissue tumors, especially small and superficial tumors;

• Poor contrast resolution;

• Low sensitivity in osteolytic lesions;

• Variable ionizing radiation.

Computed tomography

• Accessible and available;

• Multiplanar evaluation - imaging of extensive anatomical regions;

• Detects very small differences in the density of the seam;

• Rapid acquisition, short scan time, temporal resolution higher than MRI;

• Spatial resolution, definition of matrix mineralization and cortical involvement superior to MRI;

• Well-established role as a guide for bone biopsies;

• Amputation planning - customization of prostheses;

• Simulation and planning of radiotherapy treatments.

• Lower contrast resolution compared with MRI;

• Small lesions may not be incorporated into the cuts;

• Variable ionizing radiation;

• Allergic reactions to iodated contrast, which may be mild (uncommon) or severe (rare). Contraindicated use of contrast in patients allergic to iode;

Magnetic resonance imaging

• Available

• Direct multiplanar imaging;

• Devoid of ionizing radiation;

• Higher resolution of soft tissue contrast, higher than on CT;

• More sensitive in determining the extent of musculoskeletal sarcomas.

• Cost;

• Small confined space (claustrophobia, difficulties in the examinations of obese patients);

• MRI contraindications related to the generated magnetic field;

• Time for image acquisition may require sedation;

• Allergic reactions to gadolinium (very rare).

Ultrasound

• Accessible and available;

• Real-time image;

• Devoid of ionizing radiation;

• Differentiates solid tumors from cystic tumors and determines their vascularization (Doppler);

• Better at evaluating small and superficial soft tissue tumors.

• Guide soft tissue biopsies, preventing neurovascular lesions and avoiding necrotic portions of tumors;

• Use in conditions where MRI and/or CT are contraindicated.

• Examiner-dependent methodology;

• The appearance of solid tumors is usually nonspecific;

• Lower resolution and contrast to CT and MRI;

• Bone tumors cannot be evaluated;

• Tumors of larger and deeper soft tissues do not allow adequate evaluation by this modality.

mode	Advantages	Disadvantages
CT (thorax, abdomen, and pelvis)	• Accessible and available; • Chest CT: increased sensitivity in the detection of pulmonary metastasis; • CT of abdomen and pelvis: staging of synovial sarcoma, epithelioid, clear cells, leiomyosarcoma, angiosarcoma and myxoid liposarcoma.	• Ionizing radiation -^a a Estimated effective dose for adults 1-10 mSv; estimated effective dose for children 0.3-3 mSv.
Bone mapping	• Accessible and available; • Evaluation of the entire skeletal system in a single exam; • Sensitive; detects physiological changes before structural changes; • Pillar in the diagnosis and evaluation of bone metastasis; • Follow-up of lesions with high recurrence rate or metastatic potential; • Early diagnosis of skip metastasis.	• Ionizing radiation -^a a Estimated effective dose for adults 1-10 mSv; estimated effective dose for children 0.3-3 mSv. ; • Lesions not involved by reactive or very anaplastic bone may not capture (e.g., multiple myeloma, thyroid or kidney CA metastasis); • Inadequate in the evaluation of therapeutic response - flare phenomenon; • Not very specific.
FBMRI	• Differentiation between therapeutic response and disease advancement; • Superior resolution of contrast in soft parts, good spatial resolution; • Acquisition of images faster than PET/CT; • Devoid of ionizing radiation or need to use contrast; • Early diagnosis of bone metastases; • Prediction of imminent risk of fracture. • High accuracy in bone marrow study.	• Cost; • Accessibility and availability; • Time for image acquisition may require sedation; • MRI contraindications.
PET/CT	• Earlier diagnosis; • More precise staging of bone metastases than scintigraphy; • Evaluates tumor/tissue viability, access to metabolic activity; • Distinguishes residual disease from scar injuries; • Facilitates the evaluation of the therapeutic response; • Detects small pulmonary nodules; • Allows you to guide biopsies to metabolically active areas of the tumor. • Exams performed in 30 minutes;	• High cost; • Low availability; • Ionizing radiation -^b b Estimated effective dose for adults 10-30 mSv; estimated effective dose for children 3-10 mSv. ; • Limited contrast in soft parts; • Overlap in metabolic activity of benign and malignant lesions; • Infections and granulomatous processes have high glucose consumption; • CT acquisition time makes it impossible to make extra time for PET acquisition.
PET/MRI	• Earlier diagnosis; • More precise staging of bone metastases than scintigraphy; • Evaluates tumor/tissue viability, access to metabolic activity; • Allows to distinguish residual disease from scar injuries; • Facilitates the evaluation of the therapeutic response; • Allows to guide biopsies to metabolically active areas of the tumor. • Better anatomical location of lesions; • Higher than PET/CT in the CNS, liver, and spinal cord.	• High cost; • Very low availability; • Ionizing radiation -^a a Estimated effective dose for adults 1-10 mSv; estimated effective dose for children 0.3-3 mSv. ; • Protocols, indications and quantitative accuracy still under evaluation; • Time for image acquisition can exceed 1 hour; • Limited evaluation of pulmonary parenchyma.

[1] Address for correspondence Alex Guedes, PhD, Orthopedic Oncology Group, Santa Izabel Hospital, Santa Casa of Misericórdia of Bahia Marechal Floriano Street, 212, apt. 203, Canela, Salvador, BA, 40110-010, Brazil (e-mail: alexguedes2003@yahoo.com.br).

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Update in Imaging Evaluation of Bone and Soft Tissue Sarcomas

Abstract