Acquired generalized lipodystrophy under immune checkpoint inhibition

Immune checkpoint inhibitors are now the standard of care in the treatment of several types of cancer. Cutaneous immune-related adverse events (irAEs) are usually of low grade and reversible, while endocrine irAEs are generally irreversible and managed with hormone replacement therapy. We report a 47-year-old patient, treated with the anti-programmed cell death (PD)1 antibody pembrolizumab for a metastatic melanoma, who developed severe lipodystrophy after 10 months of treatment, characterized by the loss of subcutaneous fat tissue, central obesity and insulin resistance with a decreased leptin level. Histological analysis of a cutaneous biopsy revealed subcutaneous fat cell destruction associated with oedema, the presence of lipophages, and a CD3⁺ lymphocytic infiltrate involving the panniculus. This led to the diagnosis of anti-PD-1-induced acquired generalized lipodystrophy, after ruling out differential diagnoses (i.e. genetic and systemic autoimmune diseases). No corticosteroids were introduced considering the high risk of inducing severe metabolic complications, and pembrolizumab was discontinued as complete response of the melanoma was achieved. However, after 12 months of follow-up, lipodystrophy and its severe metabolic complications are still ongoing. What's already known about this topic? Anti-programmed cell death (PD)1 agents are now a standard of care in the treatment of several cancers, including melanoma. Endocrine and cutaneous immune-related adverse events (irAEs) are among the most frequent irAEs (14-30% and 30-40%, respectively) in patients treated with immune checkpoint inhibitors. What does this study add? Acquired generalized lipodystrophy can occur during anti-PD1 therapy and is associated with severe metabolic complications. With the increase in anti-PD1 prescription in several cancer types, clinicians must be aware of the whole range of irAEs that may occur.

Accuracy of computed tomographic colonography in a nationwide multicentre trial, and its relation to radiologist expertise

OBJECTIVE

Reports on the accuracy of computed tomographic colonography (CTC) mainly involve series from expert institutions. The aims of this study were to assess CTC accuracy in a nationwide population and to relate it to radiologist performance in their initial training.

DESIGN

Nationwide multicentre trial.

SETTING

Twenty-eight radiologists, working in 26 mostly academic clinical units, were involved in the study after having attended a formal specialised 2-day training session on CTC. They worked through a training set of 52 cases with automatic feedback after an attempt at each case.

PATIENTS

The study enrolled 845 patients with average and high risk of colorectal cancer, 737 of whom had both complete CTC and videocolonoscopy data, which constituted the dataset.

INTERVENTIONS

Patients underwent same-day CTC followed by videocolonoscopy with segmental unblinding of CTC results.

MAIN OUTCOME MEASURES

Sensitivity, specificity and positive and negative predictive values for detection of polyps ≥ 6 mm in per-patient and per-lesion analyses of CTC without computer-aided detection.

RESULTS

Sensitivity, specificity and positive and negative predictive values for patients with polyps ≥ 6 mm were 69% (95% CI 61% to 77%), 91% (95% CI 89% to 94%), 67% (95% CI 59% to 74%) and 92% (95% CI 90% to 94%), respectively. Univariate analysis showed that the detection rate for polyps ≥ 6 mm was linked to neither radiologist case volume nor number of polyps, but was related to sensitivity achieved in the training set. Pooled sensitivity was 72% (95% CI 63% to 80%) versus 51% (95% CI 40% to 60%) for radiologists achieving above and below median sensitivity in the training set (61%), respectively. Multivariate analysis showed that sensitivity for polyps ≥ 6 mm in the training set was the only remaining significant predictive factor for subsequent performance.

CONCLUSIONS

Radiologist sensitivity CTC for detection of polyps ≥ 6 mm in training was the sole independent predictor for subsequent sensitivity in detection of such polyps.

[Diffusion-weighted MR imaging of the breast]

Diffusion-weighted imaging is helpful to further characterize lesions that remain indeterminate after morphological and dynamic MR evaluation. Suspicious lesions are hyperintense on diffusion-weighted images with corresponding low ADC values, indicating restricted diffusion and hypercellularity. Benign lesions and tumors responding to treatment usually have no diffusion restriction. ADC maps are useful for T2W hyperintense lesions that could mask the presence of restricted diffusion. Image fusion is sometimes needed to accurately localize enhancing lesions on ADC maps. For indeterminate lesions, a hypocellular appearance suggests a lower ACR category whereas the presence of restricted diffusion suggests a higher category.

Le diagnostic d’un ganglion tumoral

There are several imaging techniques, each with advantages and limitations. Standard or computed radiography is always useful. CT diagnosis of an enlarged lymph node is easy but it is very difficult to conclude about its reactive or metastatic nature: subtle signs can help. MRI has similar pitfalls but sometimes it may be possible to identify fibrotic scarred nodes. US with Doppler can evaluate the abnormal angioarchitecture of a metastatic lymph node. Sentinel lymph nodes are easily identified by nuclear medicine. CT-PET provides morphologic and metabolic information which increases the diagnostic accuracy. Imaging work-up strategies for selected malignancies are discussed.

[The value of radiological follow-up for stage III melanoma]

INTRODUCTION

The modalities of follow-up (frequency of consultations and interest of repeated radiological examinations) of patients presenting with glandular metastases of melanoma (stage III of the AJCC classification) have not reached a consensus.

PATIENTS AND METHODS

Since 1995, we have proposed clinical follow-up every two months and radiological controls with a thoracic-abdominal-pelvic scan every 4 months, to patients at high risk of relapse for the early screening of an infra-clinical relapse.

RESULTS

The median follow-up was of 16 months (range: 1 to 82 months). Eight patients out of 24 (33 p. 100) followed-up in this manner, had asymptomatic metastases discovered by the radiological examinations. Among these 8 patients, three presented with a an operable, single, metastatic localization and two patients underwent surgery. One patient relapsed 3 months later, the other was still alive without relapse 24 months later.

DISCUSSION

Surgery remains the treatment of choice for all stages of melanoma. In the absence of clearly effective treatment of metastatic melanoma, the early discovery of an infra-clinical metastatic relapse presents two major advantages. The first is the discovery of a single, operable metastasis, as was the case in two of the patients out of 24. The second is to be able to suspend an eventual adjuvant therapy with interferon alpha, as soon as a relapse has been discovered.

[Fatty replacement of the pancreas in a patient with asymptomatic pulmonary cystic fibrosis]

The authors report the case of a 26-year-old woman with hepatomegaly, who had recurrent and progressive nausea and abdominal pain. Computed tomography and magnetic resonance imaging demonstrated fatty replacement of the entire pancreas resulting from cystic fibrosis. The pulmonary disease was totally asymptomatic. Fatty replacement of the pancreas is the most frequent pattern in older patients with cystic fibrosis. This pattern correlates with pancreatic exocrine dysfunction.

Use of voriconazole to successfully treat disseminated Trichosporon asahii infection in a patient with acute myeloid leukaemia

Trichosporon spp. is an emerging fungal pathogen in immunocompromised hosts, and disseminated infection is often fatal in neutropenic patients. Reported here is a case of disseminated infection in a neutropenic patient with acute leukaemia. After failure of amphotericin B and fluconazole therapy, the course of infection dramatically improved with voriconazole treatment. A literature search revealed 69 additional cases of disseminated Trichosporon spp. infections in neutropenic patients, and these are also reviewed. Clinical symptoms that suggest infection include fever, disseminated papulopustular cutaneous lesions and pulmonary involvement. Despite treatment with antifungal agents (amphotericin B, fluconazole), 78% of patients died. Voriconazole may represent a promising therapy for this life-threatening infection.

[Hereditary multiple exostoses after 40 years of development: a case report]

INTRODUCTION

Hereditary multiple exostoses is an autosomal dominant skeletal disorder with genetic heterogeneity and an estimated prevalence of 1/50,000 in western countries. Malignant degeneration is a rare (about 2%) but classical complication in patients with hereditary multiple exostoses. At least 3 loci identified as EXT 1, EXT 2 and EXT 3 are involved in this skeletal disease.

EXEGESIS

The case of a 45-year old man is described with 15 years follow-up after resection of a well-differentiated chondrosarcoma (grade I), which arose from a right posterior pelvic exostosis. The observed radiological lesions remained relatively stable until now. The genetic mutation which is responsible for the disease was determined at the locus EXT 1.

CONCLUSION

The present case report illustrates the natural history of hereditary multiple exostoses, especially since the patient underwent a malignant degeneration which could be resected without recurrence. The results of the genetic analysis contributed to the understanding of the pathophysiology of the disease.

Imaging of MALT lymphomas

The broad category of non-Hodgkin's lymphoma includes a large variety of different diseases including indolent as well as aggressive lymphomas. Mucosa-associated lymphoid tissue (MALT) lymphoma arises in the extranodal mucosal lymphoid tissue and has only been recognised as a distinct entity in recent years. It affects one or several extranodal structures such as the stomach, the lung, the eye and salivary glands. The lymphoma is generally of low grade and has indolent course. The aim of this article is to exemplify the most common radiological patterns of MALT lymphoma.

Cerebral and spinal cord involvement resulting from invasive aspergillosis

Although central nervous system involvement in disseminated aspergillosis is known to occur in immunocompromised patients, particularly after bone marrow transplantation, localized involvement of the spinal cord is exceedingly rare. In this report we present and illustrate detailed imaging findings of central nervous system invasion by Aspergillus fumigatus in a 30-year-old woman, with emphasis on the spinal cord involvement.

[Digital thoracic radiology: devices, image processing, limits]

In a first part, the different techniques of digital thoracic radiography are described. Since computed radiography with phosphore plates are the most commercialized it is more emphasized. But the other detectors are also described, as the drum coated with selenium and the direct digital radiography with selenium detectors. The other detectors are also studied in particular indirect flat panels detectors and the system with four high resolution CCD cameras. In a second step the most important image processing are discussed: the gradation curves, the unsharp mask processing, the system MUSICA, the dynamic range compression or reduction, the soustraction with dual energy. In the last part the advantages and the drawbacks of computed thoracic radiography are emphasized. The most important are the almost constant good quality of the pictures and the possibilities of image processing.

[Infection of a pneumonectomy site 16 years after intervention]

BACKGROUND

Infection of the residual cavity after pneumonectomy generally occurs early after surgery.

CASE REPORT

A 67-year old patient was hospitalized with fever 16 years after pneumonectomy for lung cancer. Investigations led to the diagnosis of infection of the pneumonectomy cavity.

DISCUSSION

Late infection several years after pneumonectomy is exceptional and usually occurs in a setting of bacteriemia. Diagnosis is difficult due to modifications of the thoracic signs but should be entertained whenever unexplained fever or an inflammatory syndrome occurs in a pneumonectomized patient. The thoracic CT scan shows an abnormally enlarged cavity. Bacteriological examination of evacuated fluid provides the key to diagnosis. Drainage-lavage is indicated. Surgery may be needed exceptionally.

Image-guided core-needle biopsy in patients with suspected or recurrent lymphomas

BACKGROUND

It is now commonly admitted that the diagnosis of recurrence of lymphoma can be assessed by image-guided needle biopsy (IGNB). However, the means of obtaining tissue for the original diagnosis of lymphoma is often surgery. The aim of this study was to compare the accuracy of IGNB at the time of diagnosis and at the time of recurrence or progression.

METHODS

The authors performed 212 IGNBs on 194 patients who eventually had a diagnosis of lymphoma. One hundred three IGNBs were obtained at original diagnosis and 109 at recurrence or progression. Large-cutting core-biopsy needles, ranging in size from 20 gauge to 14 gauge, were used. Immunohistochemistry studies were performed in all lymphoma cases.

RESULTS

A diagnosis of lymphoma with subtyping was obtained in 88% of all cases, in 85% at initial diagnosis, and in 89% at follow-up. Therapy was initiated on the basis of IGNB in 93% of all cases, in 91% at initial diagnosis, and in 94% at follow-up. Benign complications occurred in 7.5% of cases and did not require specific treatment. IGNB was equally effective for making a specific diagnosis of lymphoma and initiating therapy at the time of original diagnosis and at follow-up.

CONCLUSIONS

The authors recommend that IGNB be performed as the initial procedure for the diagnosis of lymphoma in the absence of peripheral lymph nodes, either at presentation or at recurrence.

Diagnostic imaging of choroid plexus disease

Disorders of the choroid plexus, a central nervous system structure, are rare, but can pose diagnostic difficulties. The purpose of this review is to illustrate the computed tomography and magnetic resonance imaging findings of a wide spectrum of lesions that affect the choroid plexus. The areas covered include (1) neoplasms (papilloma, leukaemia, meningioma, lymphoma and metastases); (2) infections (bacterial, fungal and viral); (3) cysts; (4) haemorrhage; (5) congenital abnormalities (Sturge-Weber syndrome, Klippel-Trenaunay-Weber syndrome and vascular malformations); and (6) non-infectious inflammatory disorders (xanthogranulomas, inflammatory pseudotumour, neurosarcoidosis, rheumatoid nodule and villous hypertrophy). Few of the patterns of choroid plexus involvement are specific for a particular pathological process. Guermazi, A. (2000) Clinical Radiology 55, 503-516.

[Role of MRI in the diagnosis of breast diseases]

ADVANTAGES AND LIMITATIONS: Magnetic resonance imaging of the breast is probably the most sensitive method for detecting or ruling out breast disease. It is however not as specific as expected.

TECHNIQUE

All examinations are performed with and without gadolinium intravenous administration, excepted in the case of silicone implant reconstruction mammoplasty. Dynamic contrast-enhanced MRI sequences are necessary with a permanent balance between temporal resolution, spatial resolution, and signal. MRI of the breast is not indicated as a routine examination in a screening program, neither to improve the specificity of infra-clinic lesions, nor in simply dense breasts without any known risk factor or in circumscribed masses.

INDICATIONS

MRI is best used to improved the sensitivity of mammography and sonography in selected patients. The selected indications are: evaluation of the volume and extension of breast lesions evaluation of the therapeutic response after chemotherapy, and detection or exclusion of the local recurrence in patients with breast conservation therapy.

PERSPECTIVES

The future indications and perspectives of MRI include interventional breast radiology (MRI-guided core biopsy), and thermocoagulation therapy. It may be interesting for the evaluation of patients with contrast enhanced MRI lesions with normal mammography and sonography, and also in woman with a genetically defined high breast cancer risk.

The clinical and radiological features of Fanconi's anaemia

Fanconi's anaemia is a severe refractory anaemia, associated with congenital malformations in approximately two-thirds of cases. Although these malformations may involve every organ system, suggestive dysmorphic features include growth retardation, radial ray deformities and urinary malformations. These malformations are not specific for Fanconi's anaemia, but should be recognized during pregnancy, or later in childhood, and suggest the possibility of inherited haematopoiesis disorders.

[Techniques to improve the accuracy of CT-guided abdominal biopsy]

STUDY AIM

The aim of this paper is to present an overview of the various technical progresses made in the field of CT-guided abdominal biopsies. Recent improvements allowed to markedly increase the efficiency of biopsies and to decrease the number of complications. The main innovations concern the guidance technique itself with the availability of ultra-fast CT systems, the development of automated biopsy systems, which allow to improve the size and quality of tissue samples and numerous technical tricks, allowing an easier access to target lesions, either in patient positioning or in displacement of anatomical structures. A better management of tissue samples favored by a close collaboration with pathologists is also mandatory. The last section of the paper is an overview of the rare complications of CT-guided biopsies.

Imaging findings in patients with myelofibrosis

The purpose of this review is to illustrate the wide range of radiological abnormalities in myelofibrosis. Myelofibrosis, also called myeloid metaplasia, is a myeloproliferative disorder of unknown etiology. The common imaging findings in patients with myelofibrosis are osteosclerosis, hepatosplenomegaly, and lymphadenopathies. In addition, extramedullary hematopoiesis may develop in multiple sites such as chest, abdomen, pelvis, and central nervous system, simulating malignant disease. Selected plain-film, CT, and MR images in patients with myelofibrosis are shown as pictorial essay to allow ready recognition of the most common imaging abnormalities of the disease.

Neurolymphomatosis in Waldenström's macroglobulinaemia

We report four patients with Waldenström's macroglobulinaemia with an unusual neurologic complication, neurolymphomatosis, characterized by meningeal and root nerve infiltration by lymphoplasmacytic cells. Patients presented with rapidly progressive leg proximal weakness. Examination of cerebrospinal fluid disclosed lymphoplasmacytic cells. Magnetic resonance imaging of the lumbar spine was suggestive of a tissular infiltration of leptomeninges and nerve roots. Chemotherapy and irradiation of involved tissues led to a remarkable and sustained neurological improvement.

Cervicomediastinal magnetic resonance imaging in persistent or recurrent papillary thyroid carcinoma: clinical use and limits

Cervicomediastinal magnetic resonance imaging (MRI) was evaluated in 13 consecutive persistent or recurrent papillary thyroid carcinoma (PTC) patients, previously treated by total thyroidectomy and radioiodine ablation. All had elevated thyroglobulin (Tg) levels and were therefore submitted to a new therapeutic radioiodine dose followed by a posttherapeutic whole-body scan (131I-WBS) and subsequent MRI. Patients with known distant metastases were excluded from the study. Group 1 included 7 patients with a negative 131I-WBS, whereas cervical and/or mediastinal 131I-uptake was evidenced in the other 6 patients (group 2). MRI was thus compared to 131I-WBS, and additionally in 8 reoperated cases, to histology. MRI was positive in 11 of 13 (85%) patients, corresponding to 23 of 55 (41.8%) histologically confirmed sites. In group 1, MRI was positive in 5 of 7 patients, with a sensitivity of 47% (15/32 histologically positive sites), allowing appropriate indication of surgery: 4 neck surgery, and 1 mediastinal dissection because of too distant lymph node foci. In group 2, MRI always showed more localization than 131I-WBS; histology was obtained in 3. Because all the foci located in the mediastinal area (0.8 to 1.8 cm) were histologically confirmed (7/7 sites), MRI avoided underestimation of surgery in the 8 reoperated patients. However, additional images were also observed corresponding to a normal thymus, a small neuroma or inflammatory lymph nodes, but pretracheal and very small nodes (less than 0.5 cm) were missed. In conclusion, although less specific than radioiodine scintigraphy, MRI can detect local persistent or recurrent PTC, and seems particularly effective for evaluation of mediastinal involvement.

Prognostic value of vertebral lesions detected by magnetic resonance imaging in patients with stage I multiple myeloma

We assessed the role of spinal magnetic resonance imaging (MRI) and bone densitometry as prognostic factors in patients with asymptomatic stage I multiple myeloma (MM) and negative skeletal survey. 55 consecutive patients underwent spinal MRI and 41 of them underwent bone densitometry by dual-energy X-ray absorptiometry (DEXA). Spinal MRI studies showed evidence of bone marrow involvement in 17/55 patients (31%). A diffuse pattern was present in three patients and a focal pattern in 14 patients, nine of them with only one nodular lesion. During a median follow-up of 25 months, 10 patients had disease progression, 8/17 patients with abnormal MRI and 2/38 patients with normal MRI. Median time to disease progression was not reached in both groups but was significantly different for patients with normal and those with abnormal patterns on MRI (P < 0.0001). Lumbar BMD was only slightly decreased compared with normal people (median lumbar Z score -0.43) and was not of prognostic value. Using a multivariate analysis the only two independent significant prognostic parameters were abnormal MRI (P<0.001, HR 30.4, 95% CI 4.3-213) and bone marrow plasmacytosis >20% (P=0.004, HR 16.4, 95% Cl 2.6-104). Thus, spinal MRI but not bone densitometry, appeared to be justified in patients with stage I asymptomatic MM and negative skeletal survey.

[Scanner-guided biopsy technic with abdominal compression]

The aim of this study was to present a CT-guided biopsy technique using an abdominal compression device. With this system, the digestive structures (mainly the colon and the small bowel) can be displaced away from the needle track and the distance between the skin and the target lesion can be reduced by approximately one-third. The technique has been used in 29 patients and was successful in 28, allowing node biopsies in the mesenteric, retroperitoneal or pelvic areas. The compression system is easily mounted and used standard sterilizable material. The procedure is well tolerated by patients and complication rate is not raised compared with conventional biopsy techniques.

Computed radiography

In several medical centers computed radiography has almost completely replaced the use of conventional screen-film systems for general radiography. The aim of this paper is to explain the basic principles of the four most frequently numerical detectors used in the world, with emphasis on the phosphor plates, which are the most frequently used both in hospitals and by practitioners. The other two systems are based on a receptor with selenium. The fourth uses charged coupled device (CCD) detectors. The most important principles of digital processing are then described with concentration on unsharp mask filtering. In the future computed radiography will replace standard radiology and will create a system in medicine using the power of computers to archive--with more efficiency and less space--patient medical data. The transmission of data to workstations and the processing of this data is the topic of a new field in medicine.

Pulmonary Mycobacterium avium complex disease without dissemination in HIV-infected patients

Pulmonary disease due to Mycobacterium avium complex (MAC) without evidence of dissemination is uncommon in HIV-infected patients. Five cases were observed over a 2-year period. All patients had AIDS and the median CD4 cell count at the time of presentation was 90 x 10(6)/L. Radiographic patterns included unilobar alveolar infiltrates or diffuse alveolar densities. All patients had a favorable clinical response to antimycobacterial chemotherapy with a median follow-up period of 10 months. MAC should be considered in HIV-infected patients with positive respiratory samples for acid-fast bacilli and pulmonary infiltrates. Patients with such findings in whom presumptive therapy for tuberculosis has failed should receive broad-spectrum antimycobacterial chemotherapy until final identification is available.

Radiologic anatomy of the inferior lung margins as demonstrated on computed radiography with enhancement of low frequencies

The aim of this work was to describe the radiologic anatomy of the inferior lung margins (ILMs). The method was to enhance the low frequencies of 50 normal chest computed radiographs. On each side, the anterior and posterior ILMs were divided into two halves. The frequency of visibility of each half of each ILM was calculated as their shape, lateral and medial continuities, depth, and vertebral level. The differences were compared by a paired Student t-test. The right posterior ILM was always visible and usually concave upward (94%). Its height was 8.7 +/- 1.6 cm. Its most inferior part faced L1 or L2 in 92% of cases. It was continuous medially inside with the azygo-esophageal recess in 96% of cases. The left posterior ILM was not visible laterally in 34% of cases and medially in 60% of cases. It was most often concave upward (82% of cases). Its height was 6.9 +/- 1.5 cm. Its most inferior part was at the level of L1 or L2. It was continuous medially with either the left paraspinal line or the paraaortic line. The right anterior ILM was visible in 76% of cases. It was most often oblique upward and medially (46%) or concave upward (33%) and often notched (38%). The left anterior ILM was visible in 64% of cases and more often oblique inward and upward (58%). It was continuous medially with the left inferior precardiac recess. The anterior ILMs were more variable than the posterior. The posterior ILMs were very similar in shape and inferior level and differed in depth only by the difference of height of the diaphragmatic cupolas.

Cerebral tuberculosis in patients with the acquired immunodeficiency syndrome (AIDS). Report of 6 cases and review

Cerebral tuberculosis (TB) was diagnosed in 6 (4%) of 156 HIV-infected patients with TB seen at our institution over 6 years. We describe here the clinical and radiologic features of these cases and of 15 others reported in the literature. Of the 21 patients, 59% were intravenous drug users. Presenting symptoms were fever (76%), confusion (52%), seizures (38%), and headache (38%). Fourteen patients (66%) had previous or active extracerebral TB at presentation. Cranial CT scan showed ring-(62%) or nodular-(24%) enhancing lesions or mixed forms (14%). Among the 12 patients who underwent a brain biopsy, bacteriologic evidence of TB was found in 9. Four patients (19%) died during hospitalization. Among the 17 others who received antituberculous therapy, only 1 developed neurologic sequelae. Five patients also received steroid therapy to control cerebral edema or paradoxical growth of the cerebral mass lesions. TB should be considered as a cause of cerebral mass lesions in HIV-infected patients, especially if tuberculous infection is suspected at other sites.

Sternal abscess due to Bartonella (Rochalimaea) henselae in a renal transplant patient

Bartonella henselae, previously called Rochalimaea henselae, is the causative agent of cat scratch disease (CSD) in immunocompetent subjects and bacillary angiomatosis in immunocompromised ones. Bone lesions are common in bacillary angiomatosis, but not in CSD. We present the case of a patient with a renal transplant treated by immunosuppressive therapy who developed a sternal abscess with a histological pattern of CSD. The CT pattern was that of a lytic bone lesion with adjacent fluid collection. The diagnosis was made on the basis of a polymerase chain reaction amplification performed on bone material. Bartonella henselae is a newly described bacteria that causes CSD in a normal host and bacillary angiomatosis in immunocompromised patients. We report a case of an osteolytic lesions of the sternum with adjacent fluid collection related to CSD, which occurred in a patient with a renal transplant.

[Primary cerebral lymphoma in AIDS. Retrospective study of 20 patients]

OBJECTIVES

Analyze the epidemiological pattern of primary central nervous system lymphoma in AIDS patients together with the clinical expression and course under treatment.

METHODS

We retrospectively reviewed 20 patients with AIDS-associated primary central nervous system lymphoma hospitalized in our unit between April 1992 and July 1996. Diagnosis was considered probable when an expansive intracranial process was associated with CT-scan enhancement and antitoxoplasma therapy failure in patients with extraneurological localization. Diagnosis was considered to be certain after histological confirmation.

RESULTS

Most-patients were male (19/20), with a median CD4 cell count of 9/mm3 (range 0-138). Ninety percent had AIDS before diagnosis. The presenting symptoms were mental status changes (70%), neurologic deficits (55%), fever without another cause (30%), increased intracranial pressure (25%) or seizures (25%). Opportunistic diseases were usually associated (60%). CT-scan (18/20) showed spontaneous iso or hyperdense lesions, most often solitary (67%), with nodular contrast enhancement (72%). When performed (7/20), magnetic resonance imaging showed hypointense lesions on T1-weighted images with marked contrast enhancement. Diagnosis of primary central nervous system lymphoma was suspected in 19 patients because of the failure of antitoxoplasma treatment; 4 patients had stereotactic biopsy which confirmed the diagnosis. Patients were treated with either total brain radiation therapy (10%), corticosteroids (30%), or both (60%). The median survival time after onset of symptoms was better with combined therapy or radiation therapy alone than with steroids alone (6 vs. 2 months). Interestingly, most of the patients died from neurological complications of lymphoma (85%).

DISCUSSION

The frequency of lymphoma-related death is probably due to better management of opportunistic infections and the effect of antiretroviral therapy. Further studies combining antiretroviral therapy, radiation and chemotherapy in patients with good performance status should be considered to improve the poor prognosis of AIDS-associated primary central nervous system lymphoma.

[Digital radiography of the thorax]

Digital radiography of the thorax can, now be substituted to conventional chest radiography. Computed radiography with phosphor plates and the new selenium detector are emphasized. The major image processing are explained. Successively the main other methods of digital radiography are described: scanning equalization radiography, laser-digitized radiography and multiwire proportional chambers. Then the advantages and the drawbacks of chest computed radiography are extensively reviewed.

[Cervico-mediastinal recurrences of differentiated thyroid cancers: value of MRI]

AIM

The aim of this study was to evaluate the ability of MRI to detect recurrent differentiated thyroid carcinomas developed in the neck or the upper mediastinum.

RESULTS

MRI was performed in 25 patients, and was compared in 5 cases with surgery. In 20 cases it was compared with I-131 scintigraphy (100 mCi in 14 cases and 5 mCi in 6 cases). The sensibility, specificity and overall accuracy of MRI was respectively: 100%, 66.6%, 82.6%.

COMMENTARY

MRI is a good technique to detect recurrent thyroid carcinomas. It is specially interesting to investigate patients with a biological suspicion of recurrence and a negative scintigraphy. Mediastinal localisations that cannot be detected by US can be detected by MRI.

Chest high resolution CT in adults with primary humoral immunodeficiency

The purpose of this study was to assess the findings on chest high resolution computed tomography (HRCT) in patients with primary humoral immunodeficiency. HRCT was prospectively and consecutively performed in 19 patients with primary humoral immunodeficiency, aged 15-64 years (mean 36), and in 15 healthy subjects. HRCT results were correlated with clinical and biological data. Bronchial lesions were observed in 11 patients (58%), consisting either of bronchial wall thickening in eight or bronchiectasis in eight; both were present in five patients. Lobar and/or segmental collapses were found in seven patients (37%), scars in eight patients (42%), interstitial lesions in six patients (32%), and lobular air-trapping in two patients (11%). Parenchymal collapses were correlated with the annual frequency of infections (p = 0.03) and with the IgA level (p = 0.01). Scars were correlated with the annual frequency of infections (p = 0.04). No correlation was found between bronchial wall thickening or bronchiectasis and the data analysed. In conclusion, HRCT is a useful method to demonstrate lung disease in primary humoral immunodeficiencies, with special emphasis on bronchial changes and interstitial lesions.

Imaging findings in giant pseudotumoral paraesophageal varices

We report a case of variceal changes of the azygos vein, hemiazygos vein, and paraesophageal collaterals presenting as bilateral posterior mediastinal masses in a patient with long-standing portal hypertension due to hepatosplenic schistosomiasis. The case is unusual because the varices were considerably larger than those usually encountered in portal hypertension. Dynamic CT allowed the diagnosis in demonstrating the vascular nature of these masses, which enhanced to the same degree as the other vessels. Noninvasive techniques, such as color Doppler sonography and MRI, may also be useful due to their multiplanar capabilities.

CT and MR imaging of squamous cell carcinoma of the tongue and floor of the mouth

Because contemporary treatment of oral cavity cancer involves procedures that spare the tongue and mandible, an adequate assessment of the oral cavity is essential for appropriate surgical and radiation therapy planning. Computed tomography (CT) and magnetic resonance (MR) imaging, which allow differentiation between soft tissues, are valuable tools for assessing this complex region. Their main advantage resides in their capacity to show at best the normal anatomy and the exact extent of a low-lying tumor. For display of soft tissues and tumor, MR imaging, being a multiplanar and multicontrast technique, is superior to CT. Nonenhanced T1-weighted MR imaging is better for defining the exact extent of medullary bone invasion, which appears as a low-signal-intensity area within hyperintense medullary fat. CT is optimal in detection of cortical bone invasion, which appears as an interruption or erosion of the peripheral hyperattenuating rim. Thus, in cancer of the tongue, MR imaging should be performed first. If tumor extension to the mandible is suspected (due to clinical or MR imaging findings), CT should be added. In cancer of the floor of the mouth, both MR imaging and CT should be performed in the initial work-up, especially in those cases in which there is a clinical doubt about mandibular extension of disease. The main drawback of both modalities is their lack of specificity; other methods are needed to discriminate between tumors and inflammatory or infectious diseases, particularly in the mandible. However, once the diagnosis has been confirmed histologically, treatment can be chosen based on complementary information obtained from CT and MR imaging.

Popliteal artery pseudoaneurysm revealed by deep vein thrombosis after arthroscopic meniscectomy

Arthroscopic knee surgery is a widely performed and relatively safe technique with few complications. We report a case of a young girl with a previously undescribed complication of arthroscopy consisting of the association of deep venous thrombosis and concomitant pseudoaneurysm of the popliteal artery.

Magnetic resonance imaging in patients with penile carcinoma

The aim of the study was to determine the role of pre-operative magnetic resonance imaging (MRI), with and without contrast enhancement, in patients with penile carcinoma. Nine patients with a penile cancer were studied. The staging of the tumours was performed by clinical examination, MRI and surgery, according to the TNM classification. Six patients had primary tumours, of clinical stage T1 (n = 1) and T2 (n = 5). Three other patients had been previously treated and presented with a local recurrence of clinical stage T2. Surface-coil MRI was performed at 0.5 T with T1 weighted sequences before and after gadolinium-DOTA, and T2 weighted sequences. MRI results were compared with the clinical and surgical findings. T1 weighted sequences did not clearly demonstrate the margins of the tumours. T2 weighted sequences were the more useful in five patients, whereas contrast enhanced T1 weighted sequences allowed better delineation of the lesions in only three patients. Therefore, an imaging protocol should include spin echo T2 weighted sequences. Clinical examination correctly staged six of nine tumours; MRI, seven of nine tumours and the combination of both examinations, eight of nine tumours. MRI provided good evaluation of tumoral invasion into the penile shaft.

CT and MR patterns of spinal involvement in Richter syndrome

Richter syndrome is the transformation of chronic lymphocytic leukemia (CLL) into large cell lymphoma. Besides the involvement of lymph nodes, liver, and spleen, bone lesions occur infrequently. We report one case of a patient with a paraspinous mass and destruction of the vertebra by large cell transformation of CLL seen on CT and MRI. There was nothing specific about the clinical presentation, imaging characteristics, and histopathological pattern of bone biopsy that would allow for confident differentiation from infectious spondylitis.

[Radiological aspects of invasive aspergillosis]

Invasive aspergillosis is a life-threatening illness, whose diagnosis is difficult: clinical signs are indeed not specific, and biological and mycological exams are not always conclusive. Radiological exams are essential for the diagnosis of this disease allowing to start an early intensive appropriate therapy. According to the literature and to their own experience the authors report the main radiological patterns with emphasis on the pulmonary and cerebral affections.

Factor analysis of medical image sequences in MR of head and neck tumors

PURPOSE

To evaluate factor analysis of medical image sequences (FAMIS), a means whereby physiologic contrast enhancement kinetics, called factors, and their spatial distribution, termed factor images, are estimated after acquisition of dynamic MR images. The method is intended to recognize and characterize the different tissue kinetics automatically.

METHODS

This method was evaluated in a series of 22 patients with head and neck tumors. Eleven patients presented with a previously untreated lesion. Six were examined for tumor recurrence, previously treated by multiple therapies. Five patients had preoperative chemotherapy and underwent MR before and after chemotherapy. In all cases, MR images were correlated with surgical and pathologic data. MR examinations were performed on a 1.5-T unit with static sequences and dynamic sequences acquired after bolus injection of gadolinium and processed by FAMIS.

RESULTS

FAMIS was able to identify three factors representing contrast-enhancement kinetics and their associated factor images. The neoplastic component was associated with the earlier factor image, F1. Fibrosis and chemotherapy and/or radiation-induced changes were associated with the two later factors, F2 and F3. The limits of this method were highly vascularized tissues whose earlier factor was similar to that of neoplastic tissues (mucosae and salivary glands), patient motion, responsible for artifacts in FAMIS, and lesions of less than 5 mm.

CONCLUSION

FAMIS of dynamic MR studies was useful for differentiating neoplastic tissue from tissue having undergone changes by chemotherapy and/or radiotherapy, but it did not improve the ability of MR to characterize neoplastic tissues in previously untreated patients.