The role of conventional and novel PET radiotracers in assessment of myeloma bone disease

Over 80 % of patients with multiple myeloma (MM) experience osteolytic bone lesions, primarily due to an imbalanced interaction between osteoclasts and osteoblasts. This imbalance can lead to several adverse outcomes such as pain, fractures, limited mobility, and neurological impairments. Myeloma bone disease (MBD) raises the expense of management in addition to being a major source of disability and morbidity in myeloma patients. Whole-body x-ray radiography was the gold standard imaging modality for detecting lytic lesions. Osteolytic lesions are difficult to identify at an earlier stage on X-ray since the lesions do not manifest themselves on conventional radiographs until at least 30 % to 50 % of the bone mass has been destroyed. Hence, early diagnosis of osteolytic lesions necessitates the utilization of more complex and advanced imaging modalities, such as PET. One of the PET radiotracers that has been frequently investigated in MM is 18F-FDG, which has demonstrated a high level of sensitivity and specificity in detecting myeloma lesions. However, 18F-FDG PET/CT has several restrictions, and therefore the novel PET tracers that can overcome the limitations of 18F-FDG PET/CT should be further examined in assessment of MBD. The objective of this review article is to thoroughly examine the significance of both conventional and novel PET radiotracers in the assessment of MBD. The intention is to present the information in a manner that would be easily understood by healthcare professionals from diverse backgrounds, while minimizing the use of complex nuclear medicine terminology.

Panniculitis and pancreatitis: Inflammation and necrotic mechanisms in a patient with alcohol use disorder and alarming suspicion for malignant process

Panniculitis is an inflammatory process localized to subcutaneous tissue, with etiologies including infection, malignancy, external insults, enzymatic destructive processes, and inflammatory disorders. The incidence of panniculitis manifesting as necrosis of subcutaneous fat tissue associated with pancreatic diseases is low, which may encompass associated periarthritis with bone necrosis and panniculitis (Pancreatitis, panniculitis and polyarthritis syndrome). Pancreatitis, panniculitis and polyarthritis syndrome is considered to derive from the systemic activity of enzymes within the pancreas, which leads to disturbances within the microcirculatory system, and fat necrosis of medullary bone marrow; however, the exact pathophysiology remains unknown. Here, we present a case of a 53-year-old male with a history of chronic pancreatitis who presented with lower abdominal pain found to have osteolytic pelvic lesions considered to be panniculitis secondary to pancreatitis. Our patient provided an interesting clinical picture given his alcohol use disorder, and lytic lesions which lead the team initially towards a malignant etiology of panniculitis such as myeloma; however, given his negative studies, it was presumed his panniculitis was derived from his chronic pancreatitis. Overall, additional literature is warranted regarding the extensive workup of lytic bone lesions that present in patients who have acute vs chronic pancreatitis.

Erdheim Chester Disease - Unusual Presentation with Isolated Skeletal Lytic Lesions

Introduction

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis (LCH) of unknown origin that was first described in 1930. Since then, almost 600 cases have been reported worldwide. Even though this disease primarily affects the bone, it has a varied clinical spectrum of presentation ranging from asymptomatic bone lesions to multisystem involvement. Owing to its protean manifestations ECD is often misdiagnosed or diagnosed late.

Case Report

We present a 48-year-old female with a long long-standing history of recurrent bone lesion of the tibia and multiple trivial trauma fractures of long bones. Recently, she also developed a persistent headache and painful swelling of the right shoulder and left hip joint. Radiographs revealed multiple lytic and lytic sclerotic lesions. With the probable diagnosis of LCH, she underwent biopsy which revealed features characteristic of ECD.

Conclusion

This case highlights the fact that histopathological confirmation is the key to distinguish various types of histiocytic neoplasms. Overlapping clinical and radiological features with atypical manifestations can occur in both LCH and ECD and does not rule out either of them.

Reorganization of the osteocyte lacuno-canalicular network characteristics in tumor sites of an immunocompetent murine model of osteotropic cancers

Mechanosensitive osteocytes are central regulators of bone resorption and formation. However, during the formation of bone metastases, which arise as consequences of breast and prostate cancer and skew homeostatic bone remodeling to favor osteolytic, osteosclerotic or mixed lesions, only a paucity of data exists on tumor-associated osteocyte interaction. Herein, we used a suite of high-resolution imaging and histological techniques to evaluate the effect of osteotropic cancer on cortical bone microarchitecture. Confocal imaging highlighted a direct contact between tumor cells residing in the bone marrow and osteocytes. High-resolution microcomputed tomography revealed a 10-12% larger osteocyte lacuna volume in the presence of tumor cells at day 21 after intratibial injection of EO771-Luc breast and RM1-Luc prostate cancer cells. The 3D representative of the spatial distribution of cortical bone microporosity showed i) a regional accumulation of vascular canals and large lacunae with low connectivity in osteosclerotic regions of interest and ii) an absence of vascular canals and large lacunae in osteolytic regions. These findings pinpoint the relationship between the presence of tumor cells in the bone marrow microenvironment and osteocyte lacunar characteristics and cortical bone blood vessel structure.

Suppression of cancer-associated bone loss through dynamic mechanical loading

Patients afflicted with or being treated for cancer constitute a distinct and alarming subpopulation who exhibit elevated fracture risk and heightened susceptibility to developing secondary osteoporosis. Cancer cells uncouple the regulatory processes central for the adequate regulation of musculoskeletal tissue. Systemically taxing treatments to target tumors or disrupt the molecular elements driving tumor growth place considerable strain on recovery efforts. Skeletal tissue is inherently sensitive to mechanical forces, therefore attention to exercise and mechanical loading as non-pharmacological means to preserve bone during treatment and in post-treatment rehabilitative efforts have been topics of recent focus. This review discusses the dysregulation that cancers and the ensuing metabolic dysfunction that confer adverse effects on musculoskeletal tissues. Additionally, we describe foundational mechanotransduction pathways and the mechanisms by which they influence both musculoskeletal and cancerous cells. Functional and biological implications of mechanical loading at the tissue and cellular levels will be discussed, highlighting the current understanding in the field. Herein, in vitro, translational, and clinical data are summarized to consider the positive impact of exercise and low magnitude mechanical loading on tumor-bearing skeletal tissue.

Surgical treatment of benign osteolytic lesions in the femoral head and neck: a systematic review

Background and objectives

Treatment of benign osteolytic lesions in the femoral head and neck can be extremely challenging, particularly in children with open physis or for aggressive tumors with pathological fracture. There remains the difficult management decision as to whether to perform complete excision of the involved area or only curettage. Moreover, there is no agreed consensus on the optimal approach to lesion access when performing curettage, which included the transcervical, open and direct approach. The current systematic review aims to provide guidance for selection of surgical methods in clinical practice by comparing the advantages and drawbacks of different procedures.

Methods

A comprehensive literature search of PubMed, Embase and Web of Science databases were executed for human studies restricted to the English language. The search was filtered to include studies published from January 1980 to January 2020.

Results

A total of 33 articles including 274 patients were enrolled in the final analysis. The most common diagnosis was chondroblastoma (CBT) (104, 38.0%), followed by giant cell tumor (GCT) (56, 20.4%). There were 57 (20.8%) patients with pathological fracture. Intralesional curettage was performed in 257 (93.8%) patients with the local recurrence of 12.5% at the mean follow-up of 51.5 months. The patients who were presented with open physis or curetted via transcervical approach developed higher local recurrence in patients with CBT (P < 0.001). The local recurrence rate of GCT is 33.3% after curettage, while 8 of 9 (88.9%) patients with fracture were treated successfully with joint preservation. Two of 45 (4.4%) patients developed avascular necrosis (AVN) of femoral head after surgical hip dislocation. The reported Musculoskeletal Tumor Society (MSTS) Score was comparable among patients with different approaches to curettage.

Conclusion

The majority of benign osteolytic lesions in the femoral head and neck can be treated with intralesional curettage with acceptable local tumor control and satisfactory function. The incidence of local recurrence might be decreased dramatically for lesion access under direct visualization. The native joint maintenance could be achieved even in patients with aggressive lesions presenting pathological fracture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04442-y.

Atypical presentation of colorectal carcinoma with sole multiple osteolytic bone metastases: a case report

Background

The incidence of colorectal cancer in persons aged < 50 years has been increasing. The diagnosis of colorectal cancer is not difficult if the patient has typical symptoms; however, diagnosis may be difficult in cases with atypical symptoms and signs. We present here an atypical case of metastatic colorectal cancer with fever and sudden onset paraplegia as the sole manifestations. The patient had multiple osteolytic lesions without gastrointestinal symptoms or signs, which resulted in a diagnostic delay of colorectal cancer.

Case presentation

A 46-year-old Japanese man was transferred to our hospital for evaluation of fever. He had developed fever 8 weeks previously and had been first admitted to another hospital 5 weeks ago. The patient was initially placed on antibiotics based on the suspicion of a bacterial infection. During the hospital stay, the patient experienced a sudden onset of paralysis and numbness in his both legs. Magnetic resonance imaging showed an epidural mass at the level of Th11, and the patient underwent a laminectomy. Epidural abscess and vertebral osteomyelitis were suspected, and antimicrobial treatment was continued. However, his fever persisted, and he was transferred to our hospital. Chest, abdominal, and pelvic computed tomography (CT) with contrast showed diffusely distributed osteolytic lesions. Fluorodeoxyglucose-positron-emission tomography showed high fluorodeoxyglucose accumulation in multiple discrete bone structures; however, no significant accumulation was observed in the solid organs or lymph nodes. A CT-guided bone biopsy obtained from the left iliac bone confirmed the evidence of metastatic adenocarcinoma based on immunohistochemistry. A subsequent colonoscopy showed a Borrmann type II tumor in the sigmoid colon, which was confirmed to be a poorly differentiated adenocarcinoma. As a result of shared decision-making, the patient chose palliative care.

Conclusions

Although rare, osteolytic bone metastases as the sole manifestation can occur in patients with colorectal cancer. In patients with conditions difficult to diagnose, physicians should prioritize the necessary tests based on differential diagnoses by analytical clinical reasoning, taking into consideration the patients clinical manifestation and the disease epidemiology. Bone biopsies are usually needed in patients only with sole osteolytic bone lesions; however, other rapid and useful non-invasive diagnostic tests can be also useful for narrowing the differential diagnosis.

Synthesis of sophocarpine triflorohydrazone and its proliferation inhibition and apoptosis induction activity in myeloma cells through Notch3-p53 signaling activation

Multiple myeloma is indicated by the presence of excessive monoclonal plasma cells in bone marrow, which result in the formation of osteolytic lesions. The present study investigated SCA as anti-proliferative agent for myeloma cells and explored the mechanism associated. Effect of SCA on viabilities of KRASA12 and AMO-1 cells was evaluated by MTT assay and apoptotic ratio using flow cytometry. Protein expression was investigated by western blotting and expression of genes related to Notch3-p53 signaling axis using RT-PCR assay. Increase in SCA concentration caused a significant (P < .01) reduction in KRASA12 and AMO-1 cell viability. The KRASA12 and AMO-1 cell viabilities were reduced to 29% and 21%, respectively on treatment with 21 μM doses of SCA. SCA treatment of KRASA12 and AMO-1 cells significantly (P < .05) increased apoptosis compared with untreated cells. The Bcl-2 (26 kDa) protein expression was reduced whereas the Bax (21 kDa) and cleaved caspase-3 levels elevated in SCA treated KRASA12 and AMO-1 cells. Treatment with SCA significantly promoted Hes1, p53 (53 kDa) and Hey1 mRNA expression in KRASA12 and AMO-1 cells. Treatment of KRASA12 and AMO-1 cells with SCA led to a marked reduction in Notch3 protein expression. SCA inhibits KRASA12 and AMO-1 myeloma cell proliferation by promoting pro-apoptotic proteins. Moreover, SCA treatment suppressed Hes1 and Hey1 mRNA expression and targeted Notch3 expression. Therefore, SCA may be studied further for development of treatment for myeloma.

Primary hyperparathyroidism presenting as a brown tumor in the mandible: a case report

BACKGROUND

Primary hyperparathyroidism is characterized by hypercalcemia and elevated or inappropriately normal serum levels of parathyroid hormone. Brown tumor of bone is a rare non-neoplastic lesion resulted from abnormal bone metabolism in hyperparathyroidism. However, nowadays, skeletal disease caused by primary hyperparathyroidism is uncommon. We report a case of brown tumor in the mandible as the initial exhibition of primary hyperparathyroidism associated with an atypical parathyroid adenoma.

CASE PRESENTATION

The patient was a 49-year-old female, she had a pain mass on the right mandible a year ago and was treated with root canal therapy and marginal resection. After seven months, the mass recurred and enlarged. Enhanced CT scan, laboratory examination, Ultrasonography, ^99mTc-MIBI SPECT-CT scintiscan and pathological examination were used to confirm the diagnosis of brown tumor. The patient's symptom improved after parathyroidectomy.

CONCLUSIONS

^99mTc-MIBI SPECT/CT scintigraphy is a highly sensitive examination of the localization diagnosis of hyperparathyroidism. Brown tumors should be considered in the differential diagnosis of osteolytic lesions to avoid unnecessary and harmful interventions.

Magnetic resonance imaging reveals distinct bone marrow patterns in indolent and advanced systemic mastocytosis

Systemic mastocytosis (SM) is broadly subcategorized according to mast cell (MC) burden and organ involvement into indolent (ISM), smoldering (SSM), and advanced SM (AdvSM). However, the pattern and extent of bone involvement remains controversial. In this institutional review board (IRB)-approved study, 115 patients with different forms of SM (ISM (n = 37, 32%), SSM (n = 9, 8%), and AdvSM (n = 69, 60%)) underwent a whole-body magnetic resonance imaging including sagittal and coronal T1 and turbo inversion recovery magnitude (TIRM) sequences of the spine. The evaluation included the pattern and extent of pathologic bone marrow (BM) signals in the spine and extremities, osteolytic lesions, and vertebral fractures. A pathologic BM pattern was observed in 4/37 (11%), 8/9 (89%), and 66/69 (96%); affection of the appendicular skeleton in 3/37 (8%), 8/9 (89%), and 67/69 (97%); and vertebral fractures in 7/37 (19%), 0/9, and 13/69 (19%) patients with ISM, SSM, and AdvSM, respectively. In AdvSM, pathologic BM pattern included activated (62%), diffuse sclerotic (25%), and small-spotted BM (9%), respectively. Only activated/sclerotic BM was associated with significantly higher MC burden, organ damage, and inferior median survival (2.9 years, p = 0.04). Vertebral fractures resembled classical multi-segmental osteoporotic fractures in ISM but not in AdvSM in which they were only found in activated/sclerotic BM. Only one patient with AdvSM had a focal osteolytic lesion in the femur. Activated/sclerotic BM changes of the spine and affection of the appendicular skeleton are indicative for SSM or AdvSM. Osteolytic lesions, which are very rare, and osteoporotic fractures are ineligible for the diagnosis of AdvSM.

A possible case of mycosis in a post-classical burial from La Selvicciola (Italy)

An examination of an adult male buried from the post-classical necropolis of La Selvicciola (Viterbo, Latium, Italy; 4^th-6^th centuries AD) revealed a series of skeletal lesions. The lesions, both proliferative and lytic, ranging in size from small (around 0.01 mm) to extensive (up to 16.00 mm) pits, occurred at multiple sites. A holistic approach assessed lesion type, frequency and location in a differential diagnosis, which included myeloma, metastatic carcinoma, tuberculosis, leukemia, osteomyelitis, and mycoses. It was concluded that a mycosis, specifically Cryptococcosis, was the most likely cause of these lesions. Both macroscopic analyses and X-ray scans support our diagnosis. We also provide a methodological scheme as a model for examining unknown lesion patterns.

Brucellosis in an adult female from Fate Bell Rock Shelter, Lower Pecos, Texas (4000-1300 BP)

OBJECTIVE

This project is a case study discussing the differential diagnosis of multiple osteolytic vertebral lesions typical of brucellosis from an adult female from Fate Bell Rock Shelter in the Lower Pecos, Texas (4000-1300 BP).

MATERIALS

One middle to late adult female with exceptional preservation of the vertebrae.

METHODS

All skeletal remains were observed with low power magnification and the vertebrae were examined in greater detail using computed tomography (CT).

RESULTS

Pathological conditions involving multiple osteolytic vertebral lesions such as tuberculosis, echinococcosis, and neoplastic conditions were reviewed but brucellosis is the most likely diagnosis based on the pattern and distribution of characteristic lesions.

CONCLUSIONS

Aside from this study, only one other case of brucellosis has been recognized in prehistoric North American hunter-gatherer skeletal remains.

SIGNIFICANCE

This individual represents the first case of brucellosis in a hunter-gatherer from prehistoric North America diagnosed using both macroscopic skeletal analysis and computed tomography (CT).

LIMITATIONS

Poor preservation of vertebrae make cross comparison of remains and differential diagnosis difficult.

SUGGESTIONS FOR FURTHER RESEARCH

Further review and paleopathological research is needed regarding Coxiella burnetti (Q-fever) infection as a possible contributing factor to osteolytic lesions.

Successful voriconazole treatment of Talaromyces marneffei infection in an HIV-negative patient with osteolytic lesions

Talaromyces marneffei (T. marneffei) is a dimorphic fungus that causes systemic infection in immunocompromised patients. Here, we present a case of T. marneffei infection in an immunocompetent patient with an osteolytic lesion. Diagnosis was established by fungal culture. The patient responded rapidly to intravenous voriconazole, followed by oral voriconazole. We reviewed 18 reported cases of T. marneffei infection with osteolytic lesions, which suggests a much higher rate of osteolytic lesions in immunocompetent patients than previously thought.

A probable case of metastatic carcinoma in the medieval Netherlands

Despite recent considerable gains, our knowledge of cancer in antiquity is still limited. This paper discusses an adult individual from a Dutch medieval hospital site who demonstrates osteoblastic and osteolytic lesions on the ribs, scapula, clavicle, and vertebrae. The morphology, radiographic appearance, and distribution of the skeletal lesions suggest that this individual was affected by metastatic carcinoma. This case increases the number of publications that present an osteoblastic and osteolytic response to cancer and contributes to the body of evidence for archaeological neoplastic disease. For the Netherlands, this individual presents the first published case of probable metastatic carcinoma with mixed skeletal lesions.

The utility of 3D medical imaging techniques for obtaining a reliable differential diagnosis of metastatic cancer in an Iron Age skull

In this report we present a case of neoplastic disease affecting an Iron Age skull that provides some of the earliest evidence of metastatic cancer (MC) in Western Europe. The cranium comes from the indigenous site of Baucina (Palermo, Sicily) and was recovered in a multiple burial context dated to the 6th-5th centuries BCE. The skull was attributed to an adult female and was characterized by numerous perforating lytic lesions. CT and 3D imaging analyses were crucial for obtaining a diagnosis of MC. Based on the morphology of the lytic lesions and the biological profile of our specimen, we can tentatively suggest breast carcinoma as the primary origin of the clinical manifestations recorded on the skull. This work also highlights the importance of utilizing an analytical approach to paleopathology that incorporates up-to-date CT and 3D imaging techniques.

Proximal Femoral Bone Regeneration After an Uncemented Hydroxyapatite-coated Long-stem in Revision Hip Surgery

Background:

Bone remodelling with lateral femoral cortex thinning is a major concern after extensively porous-coated long-stem in revision surgery. Extensive hydroxyapatite coated long-stems were introduced to improve osseointegration, but bone remodelling changes have not been quantified.

Objective:

The question of whether bone remodelling changes from extensive hydroxyapatite-coated long stems influence the durability of femoral revision, clinical outcome is assessed in follow-up radiographs.

Methods:

Uncemented straight monoblock hydroxyapatite-coated long-stems used in revision hip surgery for aseptic loosening were assessed in a consecutive series of 64 hips (60 patients). Mean follow-up was 8.6 years and the mean age at surgery was 70 years (27-91). The pre-operative bone defect was classified according to Paprosky. Cortical struts were not used in this series. Cortical index and femoral cortical width were measured at three different levels at different periods.

Results:

Four patients with pain under level 4 due to stem loosening needed an exchange surgery of their femoral component, but two patients rejected re-surgery. The cumulative probability of not having aseptic loosening was 91.2% (95% confidence interval 73.5-96.9) at 10 years according to Kaplan and Meier. Twenty-seven of 35 osteolytic lesions had disappeared or decreased at the last follow-up. The thickness of the lateral and medial cortex increased over the course of the study at different levels. Increases of femoral cortex thickness were greater in men and in cases with mild bone defects.

Conclusion:

Although clinical outcome of the hydroxyapatite-coated long stem in revision surgery is good but not outstanding, most osteolytic lesions heal and the femoral cortex thickness increases at different levels.

Hyperparathyroidism during Pregnancy- A Diagnostic and Therapeutic Challenge

Primary Hyperparathyroidism (PHP) is a rare event in pregnancy; Maternal complications in PHP patients can be as high as 67%. It can be overlooked easily because of many similar complaints shared by hyperparathyroidism and pregnancy such as nausea and vomiting, gastritis, bone aches, easy fatigability. Hypercalcemic crisis can develop resulting in coma and death. Neonatal effects are tetany and death in about 80% of cases. We report a case, of an antenatal woman at 30 weeks gestation with complains of painful swelling in left lower jaw and below right knee, pain over right hip joint and frequent episodes of gastritis. She was finally diagnosed to have primary hyperparathyroidism and brown tumour due to parathyroid adenoma. The baby was kept in Neonatal Intensive Care Unit (NICU) for three weeks, in view of prematurity with respiratory distress and later developed sepsis with DIC. The patient's signs and symptoms regressed after parathyroid surgery and the baby was healthy at the time of discharge. This case highlights the progressive deterioration of the patient because of lack of awareness of this disease process and its impact on maternal and foetal morbidity.

Specific bone region localization of osteolytic versus osteoblastic lesions in a patient-derived xenograft model of bone metastatic prostate cancer

Objective

Bone metastasis occurs in up to 90% of men with advanced prostate cancer and leads to fractures, severe pain and therapy-resistance. Bone metastases induce a spectrum of types of bone lesions which can respond differently to therapy even within individual prostate cancer patients. Thus, the special environment of the bone makes the disease more complicated and incurable. A model in which bone lesions are reproducibly induced that mirrors the complexity seen in patients would be invaluable for pre-clinical testing of novel treatments. The microstructural changes in the femurs of mice implanted with PCSD1, a new patient-derived xenograft from a surgical prostate cancer bone metastasis specimen, were determined.

Methods

Quantitative micro-computed tomography (micro-CT) and histological analyses were performed to evaluate the effects of direct injection of PCSD1 cells or media alone (Control) into the right femurs of Rag2^−/−γc^−/− male mice.

Results

Bone lesions formed only in femurs of mice injected with PCSD1 cells. Bone volume (BV) was significantly decreased at the proximal and distal ends of the femurs (p < 0.01) whereas BV (p < 0.05) and bone shaft diameter (p < 0.01) were significantly increased along the femur shaft.

Conclusion

PCSD1 cells reproducibly induced bone loss leading to osteolytic lesions at the ends of the femur, and, in contrast, induced aberrant bone formation leading to osteoblastic lesions along the femur shaft. Therefore, the interaction of PCSD1 cells with different bone region-specific microenvironments specified the type of bone lesion. Our approach can be used to determine if different bone regions support more therapy resistant tumor growth, thus, requiring novel treatments.

A Study of the Supratrochlear Foramen of the Humerus: Anatomical and Clinical Perspective

INTRODUCTION

The Supratrochlear Foramen (STF) is a variably shaped perforation present in the bony septum that separates the olecranon and coronoid fossae at the distal end of the humerus, between the two epicondyles. Its incidence varies widely from 0.3% to 58% in different races.

AIM

This study aims to describe its prevalence and morphometry in relation to its shape and size and distance from the epicondyles.

MATERIALS AND METHODS

A prospective study of 244 unpaired humerii, 130 of the left side and 114 of the right side of unknown age and sex were examined for the presence of STF and prevalence stated. The STF was classified according to shape and their metric assessment was carried out, along with measures of its distance from the epicodyles and trochlear margin.

RESULTS

Of the 244 humeri studied 60 showed presence of the foramen, 45 were opaque and 139 showed translucent septum. The sidewise prevalence of opacity, translucent septum and foraminae were tabulated. The commonest shape noted was oval. Other shapes such as round, triangular, rectangular, sieve and reniform were visualised. In the oval STF, transverse and vertical diameters were measured. The transverse and vertical diameters on the left were 4.9 and 3.27 mm and on the right it was 5.12 and 3.48mm respectively. The distance from the medial epicondyle, lateral epicondyle and trochlea to the STF margins was measured and the mean values were calculated separately for right and left sides. The mean diameter of the round foramen was 3.23 and 4.89mm for left and right sides respectively. In the triangular type the maximum vertical and transverse diameters were recorded. There was only one sample of the rectangular type. Its length was 4.1mm and the breadth was 2.27mm and it belonged to the right side. The reniform type totalled 7 of which 6 were of the left side. The average vertical length at the hilum was 4.52 mm and the transverse measurement was 7.44 mm. The foraminae of the right side were found to be larger, regardless of shape.

CONCLUSION

Its existence is important to the orthopaedician in the preoperative planning of nailing fractures of the distal humerus and to the radiologist for differentiating it from an osteolytic or cystic lesion.

SAPHO syndrome presenting as an osteolytic lesion of the neck

We report a case of acute-onset multifocal vertebral osteitis with a marked impact on the patient's general health. The radiological, scintigraphic and magnetic resonance findings made it necessary to carry out a differential diagnosis to distinguish it from an infiltrative neoplastic process and determine whether it had an infectious or an inflammatory etiology. The presence of noninfectious multifocal osteitis and sternoclavicular arthritis and the subsequent development of plantar pustulosis pointed to SAPHO syndrome. Treatment with infliximab led to improvement in the clinical symptoms, laboratory values and radiological abnormalities.

Association of osteolytic lesions, bone mineral loss and trabecular sclerosis with prevalent vertebral fractures in patients with multiple myeloma

PURPOSE

In patients with multiple myeloma (MM), computed tomography is widely used for staging and to detect fractures. Detecting patients at severe fracture risk is of utmost importance. However the criteria for impaired stability of vertebral bodies are not yet clearly defined. We investigated the performance of parameters that can be detected by the radiologist for discrimination of patients with and without fractures.

METHODS AND MATERIALS

We analyzed 128 whole body low-dose CT of MM patients. In all scans a QCT calibration phantom was integrated into the positioning mat (Image Analysis Phantom(®)). A QCT-software (Structural Insight) performed the volumetric bone mineral density (vBMD) measurements. Description of fracture risk was provided from the clinical radiological report. Suspected progressive disease (PD) was reported by the referring clinicians. Two radiologists that were blinded to study outcome reported on the following parameters based on predefined criteria: reduced radiodensity in the massa lateralis of the os sacrum (RDS), trabecular thickening and sclerosis of three or more vertebrae (TTS), extraosseous MM manifestations (EOM), visible small osteolytic lesions up to a length of 8mm (SO) and osteolytic lesions larger than 8mm (LO). Prevalent vertebral fractures (PVF) were defined by Genant criteria. Age-adjusted standardized odds ratios (sOR) per standard deviation change were derived from logistic regression analysis and area under the curve (AUC) from receiver operating characteristics (ROC) analyses were calculated. ROC curves were compared using the DeLong method.

RESULTS

45% of the 128 patients showed PVF (29 of 75 men, 24 of 53 women). Patients with PVF were not significantly older than patients without fractures (64.6 ± 9.2 vs. 63.3 ± 12.3 years: mean ± SD, p=0.5). The prevalence of each parameter did not differ significantly by sex. Significant fracture discrimination for age adjusted single models was provided by the parameters vBMD (OR 3.5 [1.4-8.8], AUC=0.64 ± 0.14), SO (sOR 1.6[1.1-2.2], AUC=0.63 ± 0.05), LO (sOR 2.1[1.1-4.2] AUC=0.69 ± 0.05) and RDS (sOR 2.6[1.6-4.7], AUC=0.69 ± 0.05). Multivariate models of these four parameters showed a significantly stronger association with the development of PVF (AUC=0.80 ± 0.04) than single variables. TTS showed a significant association with PVF in men(sOR 1.5 [0.8-3.0], AUC=0.63 ± 0.08), but not in women (sOR 2.3[1.4-3.7], AUC=0.70 ± 0.07). PD was significantly associated with PVF in women (sOR 1.9[1.1-3.6], AUC=0.67 ± 0.08) but not in men (sOR 1.4[0.9-2.3], AUC=0.57 ± .07). EOM were not associated with PVF (sOR 1.0[0.4-2.6], AUC=0.51 ± .05).

CONCLUSION

In multiple myeloma, focal skeletal changes in low dose CT scans show a significant association with prevalent vertebral fractures. The combination of large osteolytic lesions and loss in radiodensity as can be detected with simple CT Hounsfield measurements of the os sacrum or BMD measurements showed the strongest association to fractures and may be of value for prospective studies.

Pure Motor Axonal Neuropathy, Organomegaly, Impaired Glucose Tolerance, M Protein, Skin Changes, Multiple Plasmacytomas & Acute Interstitial Nephritis in Osteolytic Myeloma: Beyond POEMS!

The authors describe a case of 52-year-old male who presented with sudden onset deterioration of weakness of both lower limbs and retention of urine. He had 1 month history of gradually progressive weakness of legs. On examination, there were lower motor neuron signs in lower extremity, digital clubbing and a lump over left iliac fossa. Routine blood tests showed impaired glucose tolerance, confirmed by oral glucose tolerance test while renal parameters were normal. Magnetic resonance imaging of spine documented osteolytic lesions, long segment epidural mass in thoracic spine and a mass overlying the left iliac bone, both were revealed to be plasmacytoma following cytology. Ultrasonography of abdomen showed splenomegaly. Nerve conduction studies showed gross axonal, motor, asymmetric polyneuropathy with conduction block involving all the four extremities, mainly lower limbs with sensory sparing. Serum protein electrophoresis showed M spike, and bone marrow showed diffuse neoplastic plasma cell proliferation. Osteolytic lesion was present in skull radiograph. Then in the course of illness the patient developed acute renal failure due to acute interstitial nephritis as evidenced from proteinuria and kidney biopsy, which improved with steroids and chemotherapy but unfortunately we lost the patient after 2 weeks of initiation of chemotherapy.

Multiple myeloma mesenchymal stromal cells: Contribution to myeloma bone disease and therapeutics

Multiple myeloma is a hematological malignancy in which clonal plasma cells proliferate and accumulate within the bone marrow. The presence of osteolytic lesions due to increased osteoclast (OC) activity and suppressed osteoblast (OB) function is characteristic of the disease. The bone marrow mesenchymal stromal cells (MSCs) play a critical role in multiple myeloma pathophysiology, greatly promoting the growth, survival, drug resistance and migration of myeloma cells. Here, we specifically discuss on the relative contribution of MSCs to the pathophysiology of osteolytic lesions in light of the current knowledge of the biology of myeloma bone disease (MBD), together with the reported genomic, functional and gene expression differences between MSCs derived from myeloma patients (pMSCs) and their healthy counterparts (dMSCs). Being MSCs the progenitors of OBs, pMSCs primarily contribute to the pathogenesis of MBD because of their reduced osteogenic potential consequence of multiple OB inhibitory factors and direct interactions with myeloma cells in the bone marrow. Importantly, pMSCs also readily contribute to MBD by promoting OC formation and activity at various levels (i.e., increasing RANKL to OPG expression, augmenting secretion of activin A, uncoupling ephrinB2-EphB4 signaling, and through augmented production of Wnt5a), thus further contributing to OB/OC uncoupling in osteolytic lesions. In this review, we also look over main signaling pathways involved in the osteogenic differentiation of MSCs and/or OB activity, highlighting amenable therapeutic targets; in parallel, the reported activity of bone-anabolic agents (at preclinical or clinical stage) targeting those signaling pathways is commented.

A rare case of adult acute lymphoblastic leukemia presenting with paraparesis and multiple osteolytic lesions

Acute lymphoblastic leukemia presenting with bone involvement and multiple osteolytic lesions has been commonly reported in pediatric population. Various myeloid and lymphoid malignancies can rarely present with bony lesions. We are reporting an adult female patient with acute lymphoblastic leukemia who presented with paraparesis and multiple osteolytic lesions in skull initially giving false impression of multiple myeloma.