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Guo H, Zhang Z, Wang L, Yao S, Xu S, Ma S, Liu S. Diagnostic Significance of 18F-FDG PET/CT Imaging Coupled with Magnetic Resonance Imaging of the Entire Body for Bone Metastases. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:7717398. [PMID: 36247843 PMCID: PMC9532126 DOI: 10.1155/2022/7717398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 08/25/2022] [Accepted: 09/01/2022] [Indexed: 01/26/2023]
Abstract
Objective To see if 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging paired with MR diffusion imaging can help doctors diagnose bone metastases. Methods From September 2020 to December 2021, a total of 30 individuals with probable bone metastases were recruited for the trial. With an average interval of four days, MAGNETIC resonance whole-body diffusion imaging (MR whole-body diffusion imaging) was performed on each of the 30 patients who had 18F-FDG PET/CT. The SUVmax values of the group with bone metastases were compared to those of the group without bone metastases. In this study, 18F-FDG PET/CT imaging, MR whole-body diffusion imaging, and their combination were examined. The researchers compared the results when 18F-FDG PET/CT imaging, whole-body MRI diffusion scans, and their combination indicated abnormal bone lesions. By comparing the diagnostic efficacy of 18F-FDG PET/CT imaging, MR whole-body diffusion imaging, and their combination, as well as accuracy, sensitivity, and specificity, the three techniques for diagnosing bone metastases will be evaluated for diagnostic usefulness. Results: the SUV max values of patients with bone metastases were significantly different from those of patients without bone metastases, as determined by 18F-FDG PET/CT imaging (P < 0.05). Using 18F-FDG PET/CT imaging, MR whole-body diffusion imaging, and their combined detection of aberrant bone lesions in various areas, we found statistically significant differences. Conclusion The use of 18F-FDG PET/CT imaging in conjunction with MR whole-body diffusion imaging in the diagnosis of bone metastases can be very helpful.
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Affiliation(s)
- Huimin Guo
- Department of Nuclear Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Zhiwen Zhang
- Department of Ultrasound, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Li Wang
- Department of Rehabilitation, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Shuzhan Yao
- Department of Nuclear Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Shuaishuai Xu
- Department of Nuclear Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Shulin Ma
- Department of Nuclear Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Songtao Liu
- Department of Nuclear Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
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Vasdev R, DeWitt-Foy M, Elliott SP. Sacral Insufficiency Fractures After Total Pubectomy for Osteomyelitis: A Case Series. Urology 2022; 170:203-208. [PMID: 36115424 DOI: 10.1016/j.urology.2022.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/14/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To document the incidence, risk factors, and prevalence of sacral insufficiency fractures (SIF) among patients who have undergone total pubectomy for osteomyelitis. METHODS A retrospective chart review was performed of patients undergoing total pubectomy for osteomyelitis at a single institution from 2016 to 2021. Descriptive statistics and univariate analysis were performed using the Wilcoxon rank-sum test and Fisher exact test as appropriate. RESULTS Sixteen patients underwent total pubectomy for osteomyelitis. The median age was 68 years. 12/16 (75%) had previously received pelvic radiotherapy. The median BMI was 27.8 kg/m2. Eleven (68.75%) had postoperative pelvic imaging, of which 3 (27.3%) had a new SIF. One other patient had a SIF 3 days before pubectomy. Three SIFs were detected via MRI and one by CT scan. The median BMI of patients with SIF was significantly lower than those without SIF (22.4 v 30.5, p = 0.004). All patients with SIF presented with new pelvic or perineal pain without radiculopathy. Symptoms resolved for three patients with non-opioid analgesics, physical therapy, and/or a brief trial of opioids. CONCLUSIONS Sacral insufficiency fracture is a rare sequela of total pubectomy for osteomyelitis. Lower BMI is significantly associated with SIF perhaps due to reduced muscle mass or poor bone condition and, as a result, baseline pelvic instability. Medical management should be first-line therapy.
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Rickert MM, Windmueller RA, Ortega CA, Devarasetty VVNM, Volkmar AJ, Waddell WH, Mitchell PM. Sacral Insufficiency Fractures. JBJS Rev 2022; 10:01874474-202207000-00001. [PMID: 35849657 DOI: 10.2106/jbjs.rvw.22.00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures. » The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients. » Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy. » Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences. » The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.
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Affiliation(s)
- Mariel M Rickert
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Zhong X, Zhang L, Dong T, Mai H, Lu B, Huang L, Li J. Clinical and MRI features of sacral insufficiency fractures after radiotherapy in patients with cervical cancer. BMC Womens Health 2022; 22:166. [PMID: 35562706 PMCID: PMC9102937 DOI: 10.1186/s12905-022-01758-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 05/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background To determine the incidence, clinical and MRI features of sacral insufficiency fracture (SIF) after radiotherapy (RT) in patients with cervical cancer. Methods Our study included 167 patients with cervical cancer after radiotherapy that underwent pelvic MRI for follow-up. MRIs included pre-enhanced T1-weighted, coronal fat-Suppressed T2-weighted (FS-T2W) and enhanced T1-weighted imaging. The clinical and MRI dates were reviewed. The gold standard of SIF was based on radiologic findings, clinical data and follow-up at least 12 months. Results 28 patients (10.8%) with 47 sites were diagnosed with SIFs, including 9 patients with unilateral SIF and 19 patients with bilateral SIFs. The median age was 60 years (range 41–72 years), and 89.3% (25/28) of patients were postmenopausal. 64.3% (18/28) of patients were symptomatic, and 53.6% of patients (15/28) had concomitant pelvic fractures. The median interval time from RT to SIFs was 10 months (range 3–34 months). For the lesion-wise analysis based on all MR images, all lesions were detected by visualizing bone marrow edema patterns, and fracture lines were detected in 64.6% (31/47) of SIFs. No soft-tissue tumors were founded. For each MRI sequence analysis, coronal FS-T2WI detected the most bone marrow edema pattern and fracture line than T1WI or enhanced T1WI. Conclusion SIF is a common complication in cervical cancer after radiotherapy, which has some certain clinical and MRI features. Coronal FS-T2WI may be more useful to detect and characterize these fractures than other imaging sequences.
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Affiliation(s)
- Xi Zhong
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China
| | - Linqi Zhang
- Department of Nuclear Medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China
| | - Tianfa Dong
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, People's Republic of China
| | - Hui Mai
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, People's Republic of China
| | - Bingui Lu
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China
| | - Lu Huang
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China
| | - Jiansheng Li
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China.
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Sacral Insufficiency Fracture after Radiotherapy for Cervical Cancer: Appearance and Dynamic Changes on 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography. CONTRAST MEDIA & MOLECULAR IMAGING 2021; 2021:5863530. [PMID: 34887711 PMCID: PMC8629639 DOI: 10.1155/2021/5863530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/02/2021] [Indexed: 11/18/2022]
Abstract
Objective With the increasing application of radiotherapy for cervical cancer, the incidence of sacral insufficiency fracture (SIF) is increasing gradually. Incorrect or untimely treatment caused by misdiagnosis may lead to serious adverse clinical consequences. This study retrospectively analyzed SIF caused by radiotherapy regarding the appearance and dynamic changes in 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (18F-FDG) positive emission tomography (PET)/computed tomography (CT) images to improve the understanding of SIF. Materials and Methods We retrospectively examined cervical cancer patients who underwent pelvic radiotherapy and 18F-FDG PET/CT between January 2014 and January 2021. Comparative analysis of the imaging performance and follow-up data was conducted. In total, 38 patients with ages ranging from 28 to 81 years (mean age 59.2 ± 10.6 y, median age 56 y) participated in the study. The respective characteristics of the 38 patients were summarized, and diagnosis was confirmed by follow-up changes. Results Twenty-five (65.8%) of the 38 patients suffered from unilateral SIF, and 13 (34.2%) suffered from bilateral SIF. After receiving radiotherapy, SIF first appeared in 3–42 months (median, 13 months). The main 18F-FDG PET/CT manifestations of SIF were increased bone density (35/38, 92.1%), anterior sacral fracture line (28/38, 73.7%), and diffuse or linear uptake patterns parallel to the sacroiliac joint (37/38, 97.3%), with the maximum standard uptake value (SUVmax) ranging from 1.8 to 5.9 (average, 3.1). Follow-up lasted 3–59 months (mean, 14 months). The main changes in SIF were increases in the bone density and high-density range and decreases in the FDG uptake intensity and hypermetabolism range. Three patients had secondary sacral or sacroiliac joint infection (3/38, 7.9%), and 3 patients had secondary fracture and/or pelvic deformation (3/38, 7.9%). Conclusions 18F-FDG PET/CT is an effective technique for diagnosing SIF. A small fracture line in the anterior sacrum and diffuse or linear areas of high density or metabolism parallel to the sacroiliac joint were the characteristic features of SIF. The main changes in SIF were increases in the bone density and high-density range and decreases in the FDG uptake intensity and hypermetabolism range.
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Srivastava MK, Pagala RM, Kendarla V, Nallapareddy K. Technetium-99m methylene diphosphonate bone scan in evaluation of insufficiency fractures - A pictorial assay and experience from South India. World J Nucl Med 2021; 20:355-360. [PMID: 35018150 PMCID: PMC8686751 DOI: 10.4103/wjnm.wjnm_155_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 05/21/2021] [Accepted: 06/17/2021] [Indexed: 11/04/2022] Open
Abstract
Insufficiency fractures (IFs) can be challenging to diagnose due to varied presentations, and sometimes, it changes the course of treatment, as in cancer patients in whom it has to be differentiated with metastatic disease. We present the role of Technetium 99m methylene diphosphonate (99mTc-MDP) bone scan, which is a low-cost, simple to perform, whole body diagnostic investigation in the diagnosis of IFs. This is a retrospective analysis of all patients who underwent a 99mTc-MDP bone scan in a tertiary care teaching hospital during 2013-2017 and were diagnosed as having an IF on bone scan. The bone scans were performed on a dual-head gamma camera using low-energy high-resolution collimators. Of all the bone scan performed during 2013-2017, a total of 138 patients with a mean age of 57.5 ± 14.7 years were diagnosed as having IFs based on bone scan and final clinical diagnosis. Among them, the most common complaint was regional bony pain in 62% of patients, while the most common cause was osteoporosis in 47% of patients, both postmenopausal and senile osteoporosis. In all, 265 sites of fractures were identified with a fracture average of 1.9/patient, the most common site being dorsolumbar vertebrae, followed by ribs and lower limb bones. Many unusual sites were also identified such as talus, sternum, clavicle, and scapula. 99mTc-MDP bone scan, being noninvasive whole-body imaging, is a useful investigation for evaluation of IFs and in correlation with biochemical analysis and other imaging can be used to determine the etiology of IF.
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Affiliation(s)
- Madhur Kumar Srivastava
- Department of Nuclear Medicine, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Ram Manohar Pagala
- Department of Nuclear Medicine, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Vinodh Kendarla
- Department of Nuclear Medicine, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Kavitha Nallapareddy
- Department of Nuclear Medicine, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
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Sabaliauskas V, Tiškevičius S. Diagnosing sacral insufficiency fractures after radiotherapy in women with cervical cancer: Report of three cases. Radiol Case Rep 2021; 16:2938-2944. [PMID: 34401030 PMCID: PMC8350190 DOI: 10.1016/j.radcr.2021.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Diagnosing sacral insufficiency fractures (SIF) in oncology patients is a challenge to radiologists, and recognition of imaging features is essential in order to avoid misdiagnosis of bone metastases and prevent patients from inaccurate treatment. Clinical cases in order to better understand the essence of this pathology and to make diagnosis easier, we present three clinical cases of SIF in patients with cervical cancer. All patients received radiation therapy (external beam radiation and brachytherapy) and chemotherapy with cisplatin. Patients underwent pelvic MRI, CT, SPECT or SPECT/CT examinations. One patient underwent a FDG-PET/CT examination. Conclusions SPECT/CT should be included in the differential diagnostics when radiological features of pelvic bone pathology on CT or MRI are undetermined or SIF are suspected. SIF must always be considered in oncology patients with pelvic pain, especially in postmenopausal state and after radiation therapy. For patients with osteoporosis, bone density screening and precise review of the most common fracture sites are recommended.
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Chung YK, Lee YK, Yoon BH, Suh DH, Koo KH. Pelvic Insufficiency Fractures in Cervical Cancer After Radiation Therapy: A Meta-Analysis and Review. In Vivo 2021; 35:1109-1115. [PMID: 33622908 PMCID: PMC8045108 DOI: 10.21873/invivo.12356] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/02/2021] [Accepted: 01/12/2021] [Indexed: 12/29/2022]
Abstract
AIM The aim of the study was to estimate the prevalence of pelvic insufficiency fractures (PIFs) after radiation therapy (RT) in patients with cervical cancer. PATIENTS AND METHODS A total of 3,633 patients from 15 cohort studies were included. Proportion meta-analysis was performed to estimate prevalence and subgroup analysis was performed according to imaging modalities for diagnosis of PIF. For continuous variables (age and length of follow-up), meta-regression analysis was performed. RESULTS Pooled prevalence estimate of PIF was 14% (95% CI=10-19). Incidence of PIF was higher in studies that used MRI as a diagnostic tool (17%, 95% CI=12-22) than non-MRI (8%, 95% CI=2-14). In meta-regression, we found a significant association of prevalence of PIF with age (p=0.021) but not with length of follow-up (p=0.118). CONCLUSION PIF after RT in patients with cervical cancer is not rare. Physicians need to pay attention to PIFs, especially in patients with high-risk factors for osteoporotic fracture.
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Affiliation(s)
- Youn Kyung Chung
- Obstetrics and Gynecology, National Cancer Center, Goyang, Republic of Korea
| | - Young-Kyun Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Byung-Ho Yoon
- Department of Orthopedic Surgery, Inje University College of Medicine, Seoul Paik Hospital, Seoul, Republic of Korea
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea;
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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Zhong X, Jiang H, Mai H, Xiang J, Li J, Huang Z, Wu S, Luo L, Jiang K. Radiation-induced occult insufficiency fracture or bone metastasis after radiotherapy for cervical cancer? The nomogram based on quantitative apparent diffusion coefficients for discrimination. Cancer Imaging 2020; 20:76. [PMID: 33097093 PMCID: PMC7583230 DOI: 10.1186/s40644-020-00353-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 09/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background Radiation-induced insufficiency fractures (IF) is frequently occult without fracture line, which may be mistaken as metastasis. Quantitative apparent diffusion coefficient (ADC) shows potential value for characterization of benign and malignant bone marrow diseases. The purpose of this study was to develop a nomogram based on multi-parametric ADCs in the differntiation of occult IF from bone metastasis after radiotherapy (RT) for cervical cancer. Methods This study included forty-seven patients with cervical cancer that showed emerging new bone lesions in RT field during the follow-up. Multi-parametric quantitative ADC values were measured for each lesion by manually setting region of interests (ROIs) on ADC maps, and the ROIs were copied to adjacent normal muscle and bone marrow. Six parameters were calculated, including ADCmean, ADCmin, ADCmax, ADCstd, ADCmean ratio (lesion/normal bone) and ADCmean ratio (lesion/muscle). For univariate analysis, receiver operating characteristic curve (ROC) analysis was performed to assess the performance. For combined diagnosis, a nomogram model was developed by using a multivariate logistic regression analysis. Results A total of 75 bone lesions were identified, including 48 occult IFs and 27 bone metastases. There were significant differences in the six ADC parameters between occult IFs and bone metastases (p < 0.05), the ADC ratio (lesion/ muscle) showed an optimal diagnostic efficacy, with an area under ROC (AUC) of 0.887, the sensitivity of 95.8%, the specificity of 81.5%, respectively. Regarding combined diagnosis, ADCstd and ADCmean ratio (lesion/muscle) were identified as independent factors and were selected to generate a nomogram model. The nomogram model showed a better performance, yielded an AUC of 0.92, the sensitivity of 91.7%, the specificity of 96.3%, positive predictive value (PPV) of 97.8% and negative predictive value (NPV) of 86.7%, respectively. Conclusions Multi-parametric ADC values demonstrate potential value for differentiating occult IFs from bone metastasis, a nomogram based on the combination of ADCstd and ADCmean ratio (lesion/muscle) may provide an improved classification performance.
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Affiliation(s)
- Xi Zhong
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, China
| | - Huali Jiang
- Department of Cardiovascularology, Tungwah Hospital of Sun Yat-Sen University, Dong cheng East Road, Dong guan, 523110, Guangdong, China
| | - Hui Mai
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Jialin Xiang
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, 510000, China
| | - Jiansheng Li
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, China
| | - Zhiqing Huang
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, 510000, China
| | - Songxin Wu
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, 510000, China
| | - Liangping Luo
- Department of Medical Imaging, First Affiliated Hospital of Jinan University, Guangzhou, 510000, China.
| | - Kuiming Jiang
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, 510000, China.
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Abstract
Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma.This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation.Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction.Herein, we present issues, challenges and solutions related to the management of sacral fractures. Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064.
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Affiliation(s)
- Emmanuele Santolini
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Italy.,Academic Department of Trauma and Orthopaedics, LGI, University of Leeds, UK
| | | | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, LGI, University of Leeds, UK.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
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Computed Tomography (CT) Protocols Associated with Cardiac and Bone Single-Photon Emission Computed Tomography/CT (SPECT/CT) in Korea. Nucl Med Mol Imaging 2020; 54:139-146. [PMID: 32582397 DOI: 10.1007/s13139-020-00644-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE Single-photon emission computed tomography/computed tomography (SPECT/CT) is an advanced hybrid nuclear medicine technology that generates both functional and anatomical images in a single study. As utilization of SPECT/CT in Korea has been increasing, the purpose of this study was to survey its application of cardiac and skeletal SPECT/CT imaging for protocol optimization. METHODS We surveyed CT protocols established for cardiac and skeletal SPECT/CT. We searched the guidelines for the CT protocols for SPECT/CT and reviewed the literature recently published. RESULTS Among 36 hybrid SPECT scanners equipped with four or more multi-channel detector CTs (MDCTs), 18 scanners were used to perform cardiac studies at both very low current CT (30-80 mA; 11.1%) and ultra-low current CT (13-30 mA; 88.9%). Among the 33 canners, very low current (≤ 80 mA) CT or low current CT (80-130 mA) was used in 23.5%, and 41.8% for spine disorders, and in 36.4% or 30.3% for foot/ankle disorders, respectively. In the CT reconstructions, slice thickness of 5 mm for cardiac studies was most commonly used (94.4%); thinner slices (0.6-1.0 mm) for spine and foot/ankle studies were used in 24.2% and 45.5%, respectively. We also reviewed the international guidelines. CONCLUSIONS The results and current recommendations will be helpful for optimizing CT protocols for SPECT/CT. Optimization of SPECT/CT protocols will be required for generating the proper strategy for the specific lesions and clinical purpose.
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Urits I, Orhurhu V, Callan J, Maganty NV, Pousti S, Simopoulos T, Yazdi C, Kaye RJ, Eng LK, Kaye AD, Manchikanti L, Viswanath O. Sacral Insufficiency Fractures: a Review of Risk Factors, Clinical Presentation, and Management. Curr Pain Headache Rep 2020; 24:10. [PMID: 32067155 DOI: 10.1007/s11916-020-0848-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF THE REVIEW Sacral insufficiency fractures (SIF) are a common and often underdiagnosed source of low back pain. In patients with SIF, there is both a compromised sacroiliac joint and weakened sacrum, resulting in decreased resistance to torsional stress, leading to fracture. While conservative medical management is a safe option, minimally invasive intervention may provide improved short and long-term relief of low back pain in patients presenting with SIF. This comprehensive review is undertaken to provide an update to the current understanding of SIF with description of risk factors, clinical presentation, and management. RECENT FINDINGS Sacroplasty is a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is inserted into bone to improve its structural integrity and alleviate symptoms. Balloon sacroplasty (BSP) has also been successful in alleviating pain with minimal cement leakage in SIF patients. Various other interventional techniques, including navigation-assisted screw fixation have been used to address SIF and have shown improvement in pain with minimal side effects. This review included various modalities of treatments available to manage SIF. This review shows that in comparison with nonsurgical management, sacroplasty has been shown to have greater pain reduction and improved mobility.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Vwaire Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Jessica Callan
- Department of Anesthesia, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Nishita V Maganty
- Department of Anesthesia, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Sara Pousti
- Department of Anesthesia, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Thomas Simopoulos
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Cyrus Yazdi
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Rachel J Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | | | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Zhong X, Li L, Lu B, Zhang H, Huang L, Lin X, Li J, Zhang J. Differentiation of Cervical Spine Osteoradionecrosis and Bone Metastasis After Radiotherapy Detected by Bone Scan in Patients With Nasopharyngeal Carcinoma: Role of Magnetic Resonance Imaging. Front Oncol 2020; 10:15. [PMID: 32038989 PMCID: PMC6992573 DOI: 10.3389/fonc.2020.00015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/07/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Osteoradionecrosis (ORN) of the cervical spine is a serious complication after radiotherapy (RT), which may show increased radiotracer uptake on a bone scan (BS) and be mistaken as metastasis. We aimed to assess the value of magnetic resonance imaging (MRI) in the differentiation of cervical spine ORN from bone metastasis after RT detected by BS in nasopharyngeal carcinoma (NPC). Methods: In this retrospective study, 35 NPC patients who had undergone RT were enrolled, of whom 21 patients showed cervical spine ORN and 14 showed bone metastasis. New areas of increased radiotracer uptake in the cervical spine on a BS were noted in all patients, following which the patients underwent neck MRI for further assessment. Two radiologists independently reviewed two sets of images including a BS set and an MRI set (MRI with BS) and reached a consensus. The diagnostic sensitivity, specificity, and accuracy for ORN detection were calculated, and interobserver agreement was evaluated using the kappa test. Results: A total of 75 cervical spine lesions were identified (44, ORN; 31 metastases). The BS set analysis showed that the diagnostic sensitivity, specificity, and accuracy were only 38.6, 48.3, and 42.7%, respectively, for differentiation of cervical spine ORN from bone metastasis. On the other hand, the MRI set analysis showed that the diagnostic sensitivity, specificity, and accuracy increased to 86.4, 90.3, and 88.0%, respectively. The interobserver agreement for the MRI set was determined to be very good (κ = 0.92). Conclusion: MRI is a reliable technique for the further discrimination of emerging cervical spine lesions after RT detected by BS. Furthermore, it could be a better differential diagnosis technique for distinguishing ORN from metastasis and may help avoid a wrong assignment of the patient to a metastatic stage with indication for treatment with supplemental toxicity and a subsequent palliative strategy.
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Affiliation(s)
- Xi Zhong
- Department of Radiology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Li Li
- Department of Otolaryngology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bingui Lu
- Department of Radiology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Hainan Zhang
- Department of Radiology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Lu Huang
- Department of Radiology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Xinjia Lin
- Department of Radiology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Jiansheng Li
- Department of Radiology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
| | - Jian Zhang
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
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Pelvic insufficiency fracture or bone metastasis after radiotherapy for cervical cancer? The added value of DWI for characterization. Eur Radiol 2019; 30:1885-1895. [PMID: 31822977 DOI: 10.1007/s00330-019-06520-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/29/2019] [Accepted: 10/16/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES We sought to determine the added value of diffusion-weighted magnetic resonance imaging (DWI) in the differentiation of pelvic insufficiency fracture (PIF) from bone metastasis after radiotherapy in cervical cancer patients. METHODS In the present study, 42 cervical cancer patients after radiotherapy with 61 bone lesions (n = 40, PIFs; n = 21, bone metastasis) were included. Conventional MRI and DWI were performed in all patients. For qualitative imaging diagnosis, two sets of images were reviewed independently by three observers, including a conventional MRI set (unenhanced T1-weighted, T2-weighted, and enhanced T1-weighted images) and a DWI set (conventional MRIs, DW images, and ADC maps). The mean ADC value of each lesson was measured on ADC maps. The diagnostic performance was assessed by using the area under the receiver operating characteristic curve (Az), and sensitivity and specificity were determined. RESULTS For all observers, the Az value and sensitivity of the DWI set showed improvement compared with the conventional MRI set. The observer who had the least experience (3 years) demonstrated significant improvement in diagnostic performance with the addition of DWI; Az value increased from 0.804 to 0.915 (p = 0.042) and sensitivity increased from 75.0 to 92.5% (p = 0.035). The mean ADCs of the PIFs were significantly higher than the bone metastases (p < 0.001); ADC values > 0.97 × 10-3 mm2/s yielded an Az of 0.887, a sensitivity of 92.5%, and a specificity of 76.2%. CONCLUSIONS The addition of DWI to conventional MRI improved the differentiation of PIF from bone metastasis after RT in patients with cervical cancer. KEY POINTS • DWI showed additive value to conventional MRI in the differentiation of PIF from bone metastasis after RT. • For qualitative diagnosis, the addition of DWI can improve diagnostic performance compared with conventional MRI alone and can particularly improve the sensitivity. • Quantitative ADC assessment showed potential value for identifying PIF from bone metastasis.
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Zhang L, He Q, Zhou T, Zhang B, Li W, Peng H, Zhong X, Ma L, Zhang R. Accurate characterization of 99mTc-MDP uptake in extraosseous neoplasm mimicking bone metastasis on whole-body bone scan: contribution of SPECT/CT. BMC Med Imaging 2019; 19:44. [PMID: 31146746 PMCID: PMC6543637 DOI: 10.1186/s12880-019-0345-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 05/24/2019] [Indexed: 12/12/2022] Open
Abstract
Background 99mTc-labelled methylene diphosphonate (99mTc-MDP) uptake can occasionally be identified in extraosseous neoplasms on whole-body scans (WBSs) and may be misinterpreted as bone metastasis. The purpose of our study was to investigate the frequency of 99mTc-MDP uptake in extraosseous neoplasms and to assess the additional value of SPECT/CT for the localization and characterization of this unusual uptake. Methods Data from 7308 patients (SPECT/CT was performed in 2147 patients) with known cancer who underwent WBSs for metastatic work-up between May 2015 and July 2018 were retrospectively reviewed. The locations, numbers, and intensities of extraosseous 99mTc-MDP uptake were evaluated by WBS, and the intratumoural calcification was evaluated by SPECT/CT. The diagnostic accuracy of SPECT/CT in locating 99mTc-MDP uptake in extraosseous neoplasms was compared to that of WBS. Results A total of 41 patients showed 99mTc-MDP uptake in extraosseous neoplasms. Of these patients, 23 patients had uncertain lesions by WBS, and further SPECT/CT was performed. The incidence of 99mTc-MDP uptake in extraosseous neoplasms was observed to be 0.6% by WBS and 1.1% (by) SPECT/CT. During imaging analysis, WBS had an accuracy of only 35% (14/40), whereas SPECT/CT correctly located and diagnosed all 40 lesion sites in the 23 patients. Twenty-three lesion sites (57.5%, 23/40) showed moderate or high intensity of extraosseous 99mTc-MDP uptake. Of the 23 patients, 17 patients (73.9%, 18/23) with 31 lesion sites (77.5%, 31/40) presented with intratumoural calcification. Conclusions 99mTc-MDP uptake in extraosseous neoplasms can be observed as 0.6% on WBS and is usually localized to the breast, liver, and lung. Nuclear physicians should be familiar with such extraosseous uptake when interpreting WBSs. SPECT/CT offers better accuracy than WBS alone for locating the majority of lesions present with intratumoural calcification.
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Affiliation(s)
- Linqi Zhang
- Department of Nuclear Medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, 78 Hengzhigang Road, Guangzhou, 510095, Guangdong province, People's Republic of China
| | - Qiao He
- Department of Nuclear Medicine, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Er Road, Guangzhou, 510080, Guangdong province, People's Republic of China
| | - Tao Zhou
- Department of Nuclear Medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, 78 Hengzhigang Road, Guangzhou, 510095, Guangdong province, People's Republic of China
| | - Bing Zhang
- Department of Nuclear Medicine, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Er Road, Guangzhou, 510080, Guangdong province, People's Republic of China
| | - Wei Li
- Department of Nuclear Medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, 78 Hengzhigang Road, Guangzhou, 510095, Guangdong province, People's Republic of China
| | - Hao Peng
- Department of Nuclear Medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, 78 Hengzhigang Road, Guangzhou, 510095, Guangdong province, People's Republic of China
| | - Xi Zhong
- Department of Radiology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, 78 Hengzhigang Road, Guangzhou, 510095, Guangdong province, People's Republic of China
| | - Liwu Ma
- Department of Nuclear Medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, 78 Hengzhigang Road, Guangzhou, 510095, Guangdong province, People's Republic of China
| | - Rusen Zhang
- Department of Nuclear Medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, 78 Hengzhigang Road, Guangzhou, 510095, Guangdong province, People's Republic of China.
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Zhong X, Li J, Zhang L, Lu B, Yin J, Chen Z, Zhang J, Tang R. Characterization of Insufficiency Fracture and Bone Metastasis After Radiotherapy in Patients With Cervical Cancer Detected by Bone Scan: Role of Magnetic Resonance Imaging. Front Oncol 2019; 9:183. [PMID: 30984616 PMCID: PMC6447664 DOI: 10.3389/fonc.2019.00183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/04/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Insufficiency fracture (IF) can show increased uptake on a bone scan (BS). IFs are often misinterpreted as bone metastases if the characteristic "Honda sign" (H-sign) is invisible. The purpose of the present study was to evaluate the utility of magnetic resonance imaging (MRI) alone for the characterization of IF and bone metastasis after radiotherapy in patients with cervical cancer detected by BS. Materials and Methods: Our study included 40 patients with cervical cancer after radiotherapy that showed pelvic emerging increased uptake on a BS during follow-up. Then further MRI examination was performed in all patients. Two radiologists independently reviewed the MR images, and the sensitivity, specificity and accuracy were calculated based on the mean scores. Diagnostic validity of the inter-observer was calculated by using kappa statistics. The gold standard was based on radiologic findings, clinical data and follow-up at least 12 months. Results: A total of 57 emerging bone lesions detected at BS were identified in the reference standard, including 43 IFs and 14 bone metastases. Only 20 patients showed a "H-sign" on the BS images. Using MRI analysis, all lesions detected by BS were found in MRI by both radiologists. On average, the sensitivity, specificity, and accuracy for distinguishing IFs from bone metastases were 95.3% (41/43), 92.8% (13/14), and 94.7% (54/57), respectively. The inter-observer variability was determined to be very good (kappa value = 0.962). Conclusions: MRI is a reliable diagnostic technique for the further characterization of emerging lesions detected by BS, MRI shows great diagnostic efficiency in the differentiation of IF and bone metastasis.
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Affiliation(s)
- Xi Zhong
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Jiansheng Li
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Linqi Zhang
- Department of Nuclear Medicine, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Binggui Lu
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Jinxue Yin
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Zhijun Chen
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Jian Zhang
- Department of Radiation Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Rijie Tang
- Department of Radiology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
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