Ectopic hematopoietic bone marrow in the appendicular skeleton after trauma

METHODS: Combined bone scanning and immunoscintigraphy (IS) with 99mTc-monoclonal antigranulocyte antibodies were performed in two patients with suspected reactivation of chronic osteomyelitis of the lower extremity. Because bone scanning and IS were strongly positive, both patients underwent surgical intervention. RESULTS: Macroscopic findings did not show purulent infection and microbiologic results remained negative, but histology revealed unexpected ectopic bone marrow, explaining the strong uptake on IS. One patient exhibited active hematopoietic bone marrow at the former fracture site of the tibial bone. The second patient presented with interspersed bone marrow in the cortical bone of the femoral diaphysis after several intramedullary surgical procedures. CONCLUSION: Unexpected ectopic hematopoietic marrow may occur in the appendicular skeleton after trauma and repeated surgical interventions. The bone marrow shows a physiologic uptake with IS and may be misinterpreted as granulocyte accumulation due to infection. This may lead to false-positive diagnosis in cases of suspected osteomyelitis.     

Fluorine-18-FDG PET and technetium-99m antigranulocyte antibody scintigraphy in chronic osteomyelitis

The aim of this study was to assess the usefulness of PET with 2-18F-fluoro-2-deoxy-D-glucose (FDG), as compared to immunoscintigraphy (IS) with 99mTc-labeled monoclonal antigranulocyte antibodies (AGAbs), in the detection of chronic osteomyelitis. METHODS: Fifty-one patients suspected of having chronic osteomyelitis in the peripheral (n = 36) or central (n = 15) skeleton were evaluated prospectively with static FDG PET imaging and combined 99mTc-AGAb/99mTc-methylene diphosphonate (MDP) bone scanning within 5 days. FDG PET and IS were evaluated in a blinded and independent manner by visual interpretation, which was graded on a five-point scale of two observers' confident diagnosis of osteomyelitis. Receiver operating characteristic (ROC) curve analysis was performed for both imaging modalities. The final diagnosis was established by means of bacteriologic culture of surgical specimens and histopathologic analysis (n = 31) or by biopsy and clinical follow-up over 2 yr (n = 20). RESULTS: Of 51 patients, 28 had osteomyelitis and 23 did not. According to the unanimous evaluation of both readers, FDG PET correctly identified 27 of the 28 positives and 22 of the 23 negatives (IS identified 15 of 28 positives and 17 of 23 negatives, respectively). The area under the ROC curve was 0.97/0.97 (reader 1/reader 2) for FDG PET and 0.87/0.90 for IS, with a high degree of interobserver concordance (K-values were 0.96 for FDG PET and 0.91 for IS). In the central skeleton, the ROC curve area was 0.98/1.00 for FDG PET and 0.71/0.77 for IS (p<0.05). On the basis of ROC analysis, the overall accuracies of FDG PET and IS in the detection of chronic osteomyelitis were 96%/96% and 82%/ 88%, respectively. With regard to the optimal threshold values, sensitivity and specificity were 100%/97% and 95%/95% with FDG PET, compared to 86%/92% and 77%/82% with IS, respectively. CONCLUSION: In the peripheral skeleton, both FDG PET and combined 99mTc-AGAb/99mTc-MDP scanning are appropriate imaging modalities to diagnose chronic osteomyelitis. FDG PET additionally allows reliable differentiation between osteomyelitis and infection of the surrounding soft tissue. In the central skeleton within active bone marrow, FDG PET is highly accurate and superior to AGAb imaging in the diagnosis of chronic osteomyelitis, which frequently presents as a nonspecific photopenic lesion at scintigraphy with labeled white blood cells.     

Radiographic patterns of osteomyelitis in the mandible. Plain film/CT correlation

Mandibular osteomyelitis often is associated with involvement of the masticator space. Assessment of mandibular osteomyelitis should therefore involve assessment of soft tissue involvement of the lesion. The purpose of this study was to clarify the relationship between computed tomography patterns and the presence of inflammation in soft tissues. Thirty-three cases diagnosed with osteomyelitis of the mandible were analyzed radiologically with conventional radiographs and with computed tomography scans. Computed tomography patterns of osteomyelitis were classified into four types, lytic, mixed, sclerotic, and sequestrum patterns. Location, extent of the lesion, and change of the cortical plate were evaluated and compared with conventional radiographic findings. Mixed pattern cases displayed diffuse bone abnormalities, which sometimes were accompanied by cortical plate disruption and periosteal reaction. In addition, most mixed pattern cases showed soft tissue involvement, especially of the masseter muscle. Inflammation of the masseter muscle was found to be related to periosteal reaction and disruption of the buccal cortical plate. The data demonstrate a close interaction between cortical plate disruption and muscle inflammation. The extent of inflammation including soft tissue involvement was better appreciated with computed tomography in osteomyelitis, especially in mixed pattern cases.     

A case of a ruptured lingual artery aneurysm treated with endovascular surgery

A rare case of a ruptured lingual artery aneurysm treated with endovascular procedure in presented. A 67-year-old woman undergoing treatment in our hospital for right thalamic hemorrhage complained of sudden swelling in the submandibular area and breathlessness. The swelling was so rapid and progressive that her breathing was disturbed. She was intubated as soon as possible. Computed tomography (CT) showed a massive subcutaneous hematoma, extending from the left submandibular area to the neck, which had compressed the trachea to the right. CT with contrast medium showed extravasation of the medium for this lesion. Angiography showed that the aneurysm was located on the periphery of the left ingual artery. Extravasation of contrast medium from the aneurysm was also observed. We considered that direct surgery was difficult to perform safely, so we chose an endovascular procedure to treat this lesion. The lingual artery was successfully embolized using four platinum coils. No rebleeding or other complication occurred after the coil embolization. Disturbance of breathing due to air way obstruction is an important symptom of a ruptured lingual artery aneurysm. Endovascular surgery may be the first choice for treatment of the bleeding origin.     

Immunoscintigraphy of bone sarcomas--results in 5 patients

The feasibility of using the murine monoclonal antibody, TP-1, for clinical immunoscintigraphy was examined in a pilot study involving 5 patients with bone sarcomas. 131I-labelled F(ab')2 antibody fragments were injected in doses of 0.8-1.0 mg (90-130 MBq), and the accumulation of radioactivity was examined by scintigraphy, and assessed by direct measurements on biopsied tumour and normal tissue. One osteosarcoma patient had a primary tumour in the femur, whereas the other 4 had single lung metastases detected by other diagnostic methods. Immunoscintigraphy of the femoral primary was optimally visualised after 22 h. In 2 patients, the method failed to detect lung metastasis, in 1 of the cases possibly related to less than optimal methodological conditions. In 2 other patients, increased accumulation of radioactivity indicated one and three lung tumours, in addition to the single metastasis observed by X-ray and CT scanning, tumours that were later confirmed and removed surgically. The concentration of radioactivity in tumour and normal tissues 44-72 h after antibody injection could be measured in 4 patients. The tumour to blood ratios were in the range of 1.2-4.2, compared to 0.1-0.8 for various normal tissues. The results indicate that immunoscintigraphy with TP-1 antibody fragments have a potential for early detection of lung metastases in patients with bone sarcoma.     

Ovarian cancer: comparison of findings with perfluorocarbon-enhanced MR imaging, In-111-CYT-103 immunoscintigraphy, and CT

PURPOSE: To determine the accuracy of breath-hold gadolinium- and perflubron-enhanced magnetic resonance (MR) imaging, immunoscintigraphy with indium-111-CYT-103 (planar and single photon emission computed tomography [CT]), and contrast material-enhanced CT for the detection of ovarian cancer prior to laparotomy. MATERIALS AND METHODS: Sixteen patients with primary (n = 3) or treated (n = 13) ovarian cancer underwent imaging of the abdomen and pelvis with each modality. All images were reviewed prospectively for tumor location, and results were compared with findings at surgery. RESULTS: With CT or MR imaging, tumor was detected in 11 of 13 (85%) patients compared with 11 of 12 patients (92%) with immunoscintigraphy. Per patient accuracy for CT was 81% compared with 75% for MR imaging and 86% for immunoscintigraphy. For detection of individual sites of tumor, the sensitivity of MR imaging was highest (81%) compared with CT (51%, P < .001) and immunoscintigraphy (50%, P < .01). The combination of MR imaging and immunoscintigraphy depicted 89% of sites of tumor involvement confirmed at laparotomy. CONCLUSION: MR imaging and immunoscintigraphy show promise for the evaluation of patients with ovarian cancer.     

Effects of nonoxynol-9 on vaginal microflora and chlamydial infection in a monkey model

A 58-year-old male with left renal cell carcinoma and prostatic carcinoma occurring synchronously, is reported. He visited our hospital, because of the high level of serum prostate-specific antigen (PSA) pointed out in a health screening by his company. Prostatic cancer was detected in both lobes of the prostate by needle biopsy specimens and histopathology represented moderately > poorly differentiated adenocarcinoma. Magnetic resonance imaging (MRI) and computed tomography (CT) revealed no cancer invasion beyond the prostate and no lymph node metastasis. Bone scintigram showed no abnormal RI accumulation to bone. Therefore, his prostatic cancer was considered to be at stage B2. Abdominal ultrasound echogram showed the mass lesion in the left kidney. CT and angiogram also demonstrated a left renal tumor. Left radical nephrectomy was performed and histopathology showed a mixed subtype of renal cell carcinoma (stage: pT2b, pN0, pM0). Although 94 cases of double cancers associated with genitourinary organs have been reported in the Japanese literature, only 4 cases of double cancers of renal cell carcinoma and prostatic cancer have been reported.     

Radiographic assessment of changes in marginal bone around endosseous implants supporting mandibular overdentures

We report a case of primary iliopsoas abscess successfully treated by ultrasonographically guided percutaneous drainage. A 56-year-old man presented at our hospital with lumbago, right-sided back pain, fever (temperature 38.5 degrees C) and chills. On physical examination, we found dark red skin, swelling, and tenderness localized at the right side at the back of his waist. Laboratory examination showed leukocytosis (white blood cell count 9700/mm3) with a leftward shift and elevated C-reactive protein (5.2 mg/dl). Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging revealed a hypodense lesion in the right iliopsoas muscle extending to the subcutaneous tissue. About 50 ml of thick yellow pus was obtained by ultrasonographically guided aspiration drainage. A drain catheter was inserted in the abscess cavity. Laboratory findings improved and clinical symptoms abated rapidly after drainage. On the twenty-first day after drainage, US and CT showed that the abscess was no longer present. The patient was discharged after 32 days of hospitalization. As possible primary diseases causing iliopsoas abscess, such as digestive tract disease, tuberculosis, and osteomyelitis, were not found, we diagnosed the disease as primary iliopsoas abscess. Although surgical drainage has been performed in most reported cases of iliopsoas abscess, this case report shows that ultrasonographically guided percutaneous drainage is also effective for treating primary iliopsoas abscess if it is diagnosed early enough.     

Anti-CEA immunoscintigraphy might be more useful than computed tomography in the preoperative thoracic evaluation of lung cancer. A comparison between planar immunoscintigraphy, single photon emission computed tomography (SPECT), and computed tomography

While a clinical, plain radiographic, and bronchoscopic assessment yields most of the essential information needed in lung cancer, computed tomography (CT) of the thorax provides diagnostic information previously unobtainable, potentially capable of reducing the number of explorative thoracotomies. In a few recent studies, immunoscintigraphy with anti-carcinoembryonic antigen (anti-CEA) monoclonal antibodies (MA) has shown remarkable staging potential. To compare the diagnostic accuracy of the two techniques, we photoscanned with indium-111 (111In)-labeled-F(ab')2 fragments of the murine anti-CEA MA FO23C5 45 patients, who were pathologically assessed for possible loco-regional extension of lung cancer. Both planar and single photo emission computed tomography (SPECT) images were obtained. Additionally, CT of the thorax (contiguous CT slices, 10 mm thick, from the lung apices to the upper abdomen), and other routine tests of preoperative evaluation were obtained. On the basis of 37 (N1, T3, and T4), 38 (N2), and 12 (N3) pathologically documented sites, an accuracy of 65, 76, 92, 78, and 86 percent (SPECT images), and 62, 68, 42, 78, and 84 percent (CT images) was calculated (figures are relevant to N1, N2, N3, T3, and T4 disease, respectively). Thus, both techniques shared a significant margin of error in almost all the categories of evaluation; however, immunoscintigraphy showed equivalent, and, in the lymph node assessment, superior results to CT. A marginal improvement of diagnostic accuracy was recorded combining the three techniques in one case (SPECT plus planar immunoscintigraphic images), while there was no benefit in any possible integration of CT and immunoscintigraphic images. In patients with peripheral nonsquamous cell cancers, the accuracy of anti-CEA immunoscintigraphy was of 90 percent or higher. Variations in the modality of performing immunoscintigraphy, such as changes in the dose of antibody fragments to be injected, in the percentage of radiolabeling, or in the time of imaging, affected the quality of immunoscintigraphic series, and the consequent interpretation of findings. At the present time, there are very few reliable tests capable of selecting patients to proceed directly to thoracotomy or to receive some intermediate surgical test, such as a prior mediastinoscopy. Traditionally, CT has been this type of "filter-test." If current findings will be confirmed in future studies, anti-CEA immunoscintigraphy might replace CT in the evaluation of particular subgroups of patients, such as patients with peripheral nonsquamous cell bronchogenic carcinoma.     

MRI appearance of spinal lesions: metastatic tumors or infections?

Three patients with pathologically verified spinal osteomyelitis and another three with metastatic tumors of the spine were investigated. MRI of th spine of four patients showed several unusual findings. The preservation of intervertebral discs and endplates did not predict accurately the diagnosis of either infections or tumors. The "pepper and salt" appearing feature may also occur in a metastatic tumor. Plain radiographs, CT, and radioisotope bone scans were less sensitive than MRI to disclose the lesions. In cases of osteomyelitis, the systemic sources of infections were frequently not found, and the responsible microorganisms could not be identified even from the surgical specimens of two patients. However, mycobacterium tuberculosis was found in the surgical specimen of a patient with cervical spinal lesion whose MRI was indistinguishable from a metastatic tumor. Surgicopathological diagnosis was therefore crucial and mandatory in these instances.     

Cerebellar deficient folia (cdf): a new mutation on mouse chromosome 6

OBJECTIVE: To discuss the case of an 8-yr-old boy with an aneurysmal bone cyst of the right proximal humerus, including the features imaged on plain film radiography, computed tomography (CT), magnetic resonance imaging (MRI), including spin echo and fast field echo imaging. CLINICAL FEATURES: The patient suffered for 1 yr from intermittent but progressive pain in his right upper arm and shoulder area. There was no history of trauma or known systemic disease. There was decreased range of motion in abduction of the glenohumeral joint and pain on focal pressure along the deltoid muscle. A complete imaging evaluation consisting of plain film radiography, CT and MRI was performed, which revealed the classical imaging features of an aneurysmal bone cyst. An additional cystic lesion was detected by the MRI that was not appreciated on the plain films or CT. INTERVENTION AND OUTCOME: The patient was referred for biopsy to confirm the preliminary diagnosis of aneurysmal bone cyst. No treatment was instituted. CONCLUSION: Evaluation of aneurysmal bone cyst may be completed with CT scanning and more specifically with MRI MRI coronal T2, weighted images are advantageous for visualization of the main cystic lesion and any additional cysts. Fast field echo images show a better contrast between the cyst and bone marrow with extension of the cyst into the epiphysis as evident in this case. Follow-up studies revealed complete healing of the cyst with only residual densities in the humeral metaphyseal area.     

Tc-99m MIBI uptake in simultaneous thyroid and lung cancers

The authors present a patient with simultaneous follicular thyroid and small-cell lung cancers, both of which showed Tc-99m MIBI uptake. CT scans showed two masses: one involving the right lower neck including the right supraclavicular area and the right superior mediastinum, and the other involving the peripheral portion of the right upper lobe of the lung. I-131 imaging showed increased uptake in the right neck mass only. Tc-99m MIBI imaging, which was performed for evaluation of chest pain, showed intense uptake in the neck mass (tumor to heart ratios in planar and tomographic images were 0.92 and 0.96, respectively), and less uptake in the lung mass (tumor to heart ratios in planar and tomographic images were 0.53 and 0.40, respectively). Biopsy of the right supraclavicular mass revealed a follicular carcinoma, and a bronchoscopic biopsy of the right upper lobe mass revealed a small cell carcinoma.     

Bone scintigraphy in hungry bone syndrome following parathyroidectomy

A 59-yr-old man with chronic renal failure was admitted for evaluation of generalized skeletal pain and frontal bone mass, which was lytic on radiography. Bone scintigraphy demonstrated several foci of moderately increased uptake, without involvement of the skull mass. Radiographs of these lesions were compatible with brown tumors. Serum parathormone level was elevated and CT demonstrated a lower right cervical mass, consistent with parathyroid tumor. Following the removal of the mass and decrease in parathormone levels, the patient suffered from a prolonged period of hypocalcemia and his bone pain worsened. Repeat bone scintigraphy showed an increase in the number and intensity of the areas of focal uptake, consistent with hungry bone syndrome. This flare-up phenomenon is due to an increase in bone metabolism and is an uncommon finding following parathyroidectomy for primary hyperparathyroidism.     

Synovial chondromatosis in a lumbar apophyseal joint

A 31-year-old woman presented with painful swelling in the right paravertebral region that had been present for 2 years. Radiography and CT revealed an area of increased density due to multiple calcifications localized at the fourth lumbar vertebra. Histological examination revealed that the lesion consisted of nodules of hyaline cartilage, with focal areas of calcification, growing within synovial tissue.     

Frontal sinus mucocele mimicking a metastasis of papillary thyroid carcinoma

Radioiodine scans are highly specific for detecting metastases of well-differentiated thyroid carcinomas. However, false-positive 131I whole-body scans may occur as illustrated in the following case report. In a 53-yr-old patient, abnormal 131I uptake was found in the right frontal skull 4 wk after total thyroidectomy and radioiodine therapy for papillary thyroid cancer. Bone scans and planar x-rays of the skull were unremarkable and the serum thyroglobulin level was within normal limits. X-ray CT revealed a small nodule in the right frontal sinus corresponding to the pathological focus of 131I uptake. Surgical removal and histopathological examination of this lesion yielded a mucocele, a slow-growing lesion of the paranasal sinuses accumulating mucous material. The postoperative 131I scan was unremarkable. The possibility of a false-positive finding on radioiodine scans should be considered, particularly when the serum thyroglobulin level is not elevated.     

Shoulder dystocia and symphysiotomy: a case report

Six patients were examined by CT following head trauma, with bleeding from the ear and trismus. The mandibular condyles were normal and MRI in two patients demonstrated a normally located meniscus. An unilateral comminuted temporal bone fracture (TBF) with multiple fracture lines and one or more fragments detached from the petrous bone was demonstrated by CT in every patient. On physical examination there was trismus, inability to chew and local pain in the temporomandibular joint (TMJ) without tenderness and swelling. Measurements of vertical and horizontal mandibular movement unequivocally demonstrated TMJ malfunction in comparison with 10 controls. The malfunction was presumably due to instability of the fractured petrous bone, base of the TMJ. Immobilising one TMJ results in blocking of both joints. Clinical improvement in 6-8 months and absence of symptoms of joint derangement on repeated physical examination were thought to be explained by restored petrous bone stability following healing of the fractures. The phenomenon of trismus following TBF with normal TMJ is rare and not yet reported.     

Heart rate variability and baroreflex sensitivity in hypertensive subjects with and without metabolic features of insulin resistance syndrome

PURPOSE: The traditional approach to investigating suspected osteomyelitis in children includes conventional radiography and bone scintigraphy. The roles of US, CT and MR imaging are controversial. Our objective was to determine whether the additional use of these modalities would yield information likely to lead to treatment modification. MATERIAL AND METHODS: Sixty-five children with clinically suspected osteomyelitis took part in a prospective study. All patients underwent conventional radiography and bone scintigraphy. In addition to this, US, CT and MR imaging were all performed in 33 patients; the remaining 32 patients were examined with various combinations of these three modalities. The value of the additional information obtained was estimated retrospectively by a pediatric orthopedic surgeon in terms of possible modification of treatment. RESULTS: MR imaging was the modality with the highest sensitivity and specificity for detecting osteomyelitis. MR yielded information likely to influence treatment in the greatest proportion of patients (45%) followed by US (30%). CONCLUSION: The standard investigation protocol with the addition of US (because of its ability to detect subperiosteal abscesses early and simply) is adequate in uncomplicated cases. When additional imaging is required to outline a lesion, or in complicated cases, and when bone scintigraphy is inconclusive, MR imaging should also be performed. CT should be considered when MR investigation is not available or when anesthesia is required but cannot be provided.     

Effects of Trp64Arg mutation in the beta 3-adrenergic receptor gene on body fat, plasma glucose level, lipid profile, insulin secretion and action in Chinese

A case of concurrent enchondroma and periosteal chondroma of the right proximal humerus in a 19-year-old woman is reported. Radiographs and CT scans showed a periosteal lesion with saucerization and spicula-like mineralization of the lateral aspect of the right proximal humerus and an ill-defined irregular lucency with stippled calcifications of the medullary cavity adjacent to it. MRI showed a long intramedullary lesion in addition to the surface lesion. There was no cortical disruption by imaging and gross examination. Histologically, both lesions showed benign cartilaginous tumors; concurrent enchondroma and periosteal chondroma of the humerus was therefore diagnosed. This combination in the same bone in a patient without enchondromatosis is exceedingly rare. Radiographic features may be confused with chondrosarcoma.     

PET imaging of prostate cancer using carbon-11-choline

Prostate cancer is difficult to visualize using current techniques. Recently, 31P magnetic resonance spectroscopy has revealed that the tumor, in general, is characterized by an increased uptake of choline into the cell to meet increased synthesis of phosphatidylcholine, an important cell membrane phospholipid. We succeeded in using 11C-choline to visualize prostate cancer and its local metastasis in PET. METHODS: PET was performed on 10 prostate cancer patients from the level of pelvis to the lower abdomen. After transmission scanning, 370 MBq 11C-choline were injected intravenously. The emission scan was performed 5-15 min postinjection. Finally, PET images were displayed so that each pixel was painted by a specified color representing the degree of the standardized uptake value (SUV). The 11C-choline image was compared with the 18F-fluorodeoxyglucose (FDG) image obtained from the same patient. RESULTS: Imaging of prostate cancer and its local metastasis was difficult when 18F-FDG was used because, within the pelvis, the areas of high uptake were concealed by the overwhelmingly abundant radioactivity in urine (in ureters and bladder). By contrast, it was easy when 11C-choline was used because the urinary activity was negligible and tumor uptake was marked. The radioactivity concentration of 11C-choline in prostate cancer and metastatic sites was at an SUV of more than three in most cases. The SUV of 18F-FDG was considerably lower than that of 11C-choline. CONCLUSION: Prostate cancer and its local metastasis were visualized clearly in PET using 11C-choline.     

Primary intraosseous hemangioma of the orbit: CT and MR appearance

An 8-year-old girl had acute onset of blurred vision, proptosis, and lateral and vertical gaze palsies on the right. CT and MR examinations showed an expansile mass involving the greater wing of the right sphenoid bone. Pathologic analysis of the surgical specimen revealed a capillary hemangioma. The lesion was inhomogeneous but predominantly isointense with gray matter on T1-weighted images. On T2-weighted images the lesion was inhomogeneous with areas of both high and low signal intensity. The rim enhanced uniformly, and there was inhomogeneous enhancement of the bulk of the lesion.