Deep learning for automatic organ and tumor segmentation in nanomedicine pharmacokinetics

Rationale: Multimodal imaging provides important pharmacokinetic and dosimetry information during nanomedicine development and optimization. However, accurate quantitation is time-consuming, resource intensive, and requires anatomical expertise. Methods: We present NanoMASK: a 3D U-Net adapted deep learning tool capable of rapid, automatic organ segmentation of multimodal imaging data that can output key clinical dosimetry metrics without manual intervention. This model was trained on 355 manually-contoured PET/CT data volumes of mice injected with a variety of nanomaterials and imaged over 48 hours. Results: NanoMASK produced 3-dimensional contours of the heart, lungs, liver, spleen, kidneys, and tumor with high volumetric accuracy (pan-organ average %DSC of 92.5). Pharmacokinetic metrics including %ID/cc, %ID, and SUVmax achieved correlation coefficients exceeding R = 0.987 and relative mean errors below 0.2%. NanoMASK was applied to novel datasets of lipid nanoparticles and antibody-drug conjugates with a minimal drop in accuracy, illustrating its generalizability to different classes of nanomedicines. Furthermore, 20 additional auto-segmentation models were developed using training data subsets based on image modality, experimental imaging timepoint, and tumor status. These were used to explore the fundamental biases and dependencies of auto-segmentation models built on a 3D U-Net architecture, revealing significant differential impacts on organ segmentation accuracy. Conclusions: NanoMASK is an easy-to-use, adaptable tool for improving accuracy and throughput in imaging-based pharmacokinetic studies of nanomedicine. It has been made publicly available to all readers for automatic segmentation and pharmacokinetic analysis across a diverse array of nanoparticles, expediting agent development.

Adjuvant Auger Electron-Emitting Radioimmunotherapy with [111In]In-DOTA-Panitumumab in a Mouse Model of Local Recurrence and Metastatic Progression of Human Triple-Negative Breast Cancer

Triple-negative breast cancer (TNBC) has a high risk for recurrence and metastasis. We studied the effectiveness of Auger electron (AE) radioimmunotherapy (RIT) with antiepidermal growth factor receptor (EGFR) panitumumab conjugated with DOTA complexed to 111In ([111In]In-DOTA-panitumumab) for preventing metastatic progression after local treatment of 231/LM2-4 Luc+ human TNBC tumors in the mammary fat pad of NRG mice. Prior to RIT, the primary tumor was resected, and tumor margins were treated with X-irradiation (XRT; 5 days × 6 Gy/d). RIT was administered 1 day post-XRT by intravenous injection of 26 MBq (15 μg) or 2 × 10 MBq (15 μg each) separated by 7 d. These treatments were compared to tumor resection with or without XRT combined with DOTA-panitumumab (15 μg) or irrelevant [111In]In-DOTA-IgG2 (24 MBq; 15 μg), and efficacy was evaluated by Kaplan-Meier survival curves. The effect of [111In]In-DOTA-panitumumab (23 MBq; 15 μg) after tumor resection without local XRT was also studied. Tumor resection followed by XRT and RIT with 26 MBq [111In]In-DOTA-panitumumab significantly increased the median survival to 35 d compared to tumor resection with or without XRT (23-24 d; P < 0.0001). Local treatment with tumor resection and XRT followed by 2 × 10 MBq of [111In]In-DOTA-panitumumab, DOTA-panitumumab, or [111In]In-DOTA-IgG2 did not significantly improve median survival (26 days for all treatments). RIT alone with [111In]In-DOTA-panitumumab postresection of the tumor without XRT increased median survival to 29 days, though this was not significant. Despite significantly improved survival in mice treated with tumor resection, XRT, and RIT with [111In]In-DOTA-panitumumab, all mice eventually succumbed to advanced metastatic disease by 45 d post-tumor resection. SPECT/CT with [111In]In-DOTA-panitumumab, PET/MRI with [64Cu]Cu-DOTA-panitumumab F(ab')2, and PET/CT with [18F]FDG were used to detect recurrent and metastatic disease. Uptake of [111In]In-DOTA-panitumumab at 4 d p.i. in the MFP tumor was 26.8 ± 9.7% ID/g and in metastatic lymph nodes (LN), lungs, and liver was 34.2 ± 26.9% ID/g, 17.5 ± 6.0% ID/g, and 9.4 ± 2.4%ID/g, respectively, while uptake in the lungs (6.0 ± 0.9% ID/g) and liver (5.2 ± 2.9% ID/g) of non-tumor-bearing NRG was significantly lower (P < 0.05). Radiation-absorbed doses in metastatic LN, lungs, and liver were 9.7 ± 6.1, 6.4 ± 2.1, and 10.9 ± 2.7 Gy, respectively. In conclusion, we demonstrated that RIT with [111In]In-DOTA-panitumumab combined with tumor resection and XRT significantly improved the survival of mice with recurrent TNBC. However, the aggressive nature of 231/LM2-4 Luc+ tumors in NRG mice may have contributed to the tumor recurrence and progression observed.

Dose predictions for [177Lu]Lu-DOTA-panitumumab F(ab')2 in NRG mice with HNSCC patient-derived tumour xenografts based on [64Cu]Cu-DOTA-panitumumab F(ab')2 - implications for a PET theranostic strategy

Background

Epidermal growth factor receptors (EGFR) are overexpressed on many head and neck squamous cell carcinoma (HNSCC). Radioimmunotherapy (RIT) with F(ab')₂ of the anti-EGFR monoclonal antibody panitumumab labeled with the β-particle emitter, ¹⁷⁷Lu may be a promising treatment for HNSCC. Our aim was to assess the feasibility of a theranostic strategy that combines positron emission tomography (PET) with [⁶⁴Cu]Cu-DOTA-panitumumab F(ab')₂ to image HNSCC and predict the radiation equivalent doses to the tumour and normal organs from RIT with [¹⁷⁷Lu]Lu-DOTA-panitumumab F(ab')₂.

Results

Panitumumab F(ab')₂ were conjugated to DOTA and complexed to ⁶⁴Cu or ¹⁷⁷Lu in high radiochemical purity (95.6 ± 2.1% and 96.7 ± 3.5%, respectively) and exhibited high affinity EGFR binding (K_d = 2.9 ± 0.7 × 10^− 9 mol/L). Biodistribution (BOD) studies at 6, 24 or 48 h post-injection (p.i.) of [⁶⁴Cu]Cu-DOTA-panitumumab F(ab')₂ (5.5–14.0 MBq; 50 μg) or [¹⁷⁷Lu]Lu-DOTA-panitumumab F(ab')₂ (6.5 MBq; 50 μg) in NRG mice with s.c. HNSCC patient-derived xenografts (PDX) overall showed no significant differences in tumour uptake but modest differences in normal organ uptake were noted at certain time points. Tumours were imaged by microPET/CT with [⁶⁴Cu]Cu-DOTA-panitumumab F(ab')₂ or microSPECT/CT with [¹⁷⁷Lu]Lu-DOTA-panitumumab F(ab')₂ but not with irrelevant [¹⁷⁷Lu]Lu-DOTA-trastuzumab F(ab')₂. Tumour uptake at 24 h p.i. of [⁶⁴Cu]Cu-DOTA-panitumumab F(ab')₂ [14.9 ± 1.1% injected dose/gram (%ID/g) and [¹⁷⁷Lu]Lu-DOTA-panitumumab F(ab')₂ (18.0 ± 0.4%ID/g) were significantly higher (P < 0.05) than [¹⁷⁷Lu]Lu-DOTA-trastuzumab F(ab')₂ (2.6 ± 0.5%ID/g), demonstrating EGFR-mediated tumour uptake. There were no significant differences in the radiation equivalent doses in the tumour and most normal organs estimated for [¹⁷⁷Lu]Lu-DOTA-panitumumab F(ab')₂ based on the BOD of [⁶⁴Cu]Cu-DOTA-panitumumab F(ab')₂ compared to those estimated directly from the BOD of [¹⁷⁷Lu]Lu-DOTA-panitumumab F(ab')₂ except for the liver and whole body which were modestly underestimated by [⁶⁴Cu]Cu-DOTA-panitumumab F(ab')₂. Region-of-interest (ROI) analysis of microPET/CT images provided dose estimates for the tumour and liver that were not significantly different for the two radioimmunoconjugates. Human doses from administration of [¹⁷⁷Lu]Lu-DOTA-panitumumab F(ab')₂ predicted that a 2 cm diameter HNSCC tumour in a patient would receive 1.1–1.5 mSv/MBq and the whole body dose would be 0.15–0.22 mSv/MBq.

Conclusion

A PET theranostic strategy combining [⁶⁴Cu]Cu-DOTA-panitumumab F(ab')₂ to image HNSCC tumours and predict the equivalent radiation doses in the tumour and normal organs from RIT with [¹⁷⁷Lu]Lu-DOTA-panitumumab F(ab')₂ is feasible. RIT with [¹⁷⁷Lu]Lu-DOTA-panitumumab F(ab')₂ may be a promising approach to treatment of HNSCC due to frequent overexpression of EGFR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41181-021-00140-1.

Site-Specific Conjugation of Metal-Chelating Polymers to Anti-Frizzled-2 Antibodies via Microbial Transglutaminase

Metal-chelating polymer-based radioimmunoconjugates (RICs) are effective agents for radioimmunotherapy but are currently limited by nonspecific binding and off-target organ uptake. Nonspecific binding appears after conjugation of the polymer to the antibody and may be related to random lysine conjugation since the polymers themselves do not bind to cells. To investigate the role of conjugation sites on nonspecific binding of polymer RICs, we developed a microbial transglutaminase reaction to prepare site-specific antibody-polymer conjugates. The reaction was enabled by introducing a Q-tag (i.e., 7M48) into antibody (i.e., Fab) fragments and synthesizing a polyglutamide-based metal-chelating polymer with a PEG amine block to yield substrates. Mass spectrometric analyses confirmed that the microbial transglutaminase conjugation reaction was site-specific. For comparison, random lysine conjugation analogs with an average of one polymer per Fab were prepared by bis-aryl hydrazone conjugation. Conjugates were prepared from an anti-frizzled-2 Fab to target the Wnt pathway, along with a nonbinding specificity control, anti-Luciferase Fab. Fabs were engineered from a trastuzumab-based IgG1 framework and lack lysines in the antigen-binding site. Conjugates were analyzed for thermal conformational stability by differential scanning fluorimetry, which showed that the site-specific conjugate had a similar melting temperature to the parent Fab. Binding assays by biolayer interferometry showed that the site-specific anti-frizzled-2 conjugate maintained high affinity to the antigen, while the random conjugate showed a 10-fold decrease in affinity, which was largely due to changes in association rates. Radioligand cell-binding assays on frizzled-2+ PANC-1 cells and frizzled-2- CHO cells showed that the site-specific anti-frizzled-2 conjugate had ca. 4-fold lower nonspecific binding compared to the random conjugate. Site-specific conjugation appeared to reduce nonspecific binding associated with random conjugation of the polymer in polymer RICs.

Imaging of HER2-Positive Tumors in NOD/SCID Mice with Pertuzumab Fab-Hexahistidine Peptide Immunoconjugates Labeled with [99mTc]-(I)-Tricarbonyl Complex

PURPOSE

Molecular imaging of tumor HER2 expression may allow patient selection for HER2-targeted therapies. Our aim was to introduce hexahistidine (His₆) peptides into pertuzumab Fab to enable labeling with the [^99mTc(CO)₃(H₂O)₃]⁺ complex and study these radioimmunoconjugates for microSPECT/CT imaging of HER2-positive tumor xenografts in mice.

PROCEDURES

Fab were produced by papain digestion of pertuzumab and reacted with sulfo-SMCC for conjugation to His₆-containing peptides (CGYGGHHHHHH). His₆-peptide conjugation was measured by a radiometric assay. His₆-pertuzumab Fab were labeled at 0.4-1.0 MBq/μg with [^99mTc(CO)₃(H₂O)₃]⁺ for 1 h at 37 °C. HER2 immunoreactivity was assessed in a direct (saturation) binding assay using HER2-overexpressing SK-BR-3 human breast cancer (BC) cells. MicroSPECT/CT and biodistribution studies were performed in NOD/SCID mice with HER2-positive s.c. SK-OV-3 human ovarian cancer, or MDA-MB-361 or MDA-MB-231 human BC xenografts at 4 or 24 h post i.v. injection of [^99mTc]His₆-pertuzumab Fab (29-49 MBq, 70 μg). The specificity of tumor uptake was assessed by comparison to irrelevant [^99mTc]Fab 3913 in SK-OV-3 tumor-bearing mice.

RESULTS

SDS-PAGE analysis demonstrated cleavage of pertuzumab to produce Fab, which eluted as a single peak with a retention time of 13.8 min on SE-HPLC. Fab were conjugated to 2.1 ± 0.5 His₆ peptides and labeled with [^99mTc(CO)₃(H₂O)₃]⁺ to a radiochemical purity of 92-97 % at 0.4-0.8 MBq/μg. [^99mTc]His₆-pertuzumab Fab exhibited saturable and specific binding to SK-BR-3 cells with a K_D = 51.3 ± 5.2 × 10^-9 M and B_max = 3.5 ± 0.1 × 10⁶ receptors/cell. SK-OV-3 tumors were imaged at 4 and 24 h p.i [^99mTc]His₆-pertuzumab Fab. Tumor uptake at 24 h p.i. was 4.1 ± 0.6 %ID/g, which was 13-fold significantly greater than [^99mTc]Fab 3913 (0.3 ± 0.0 %ID/g; P < 0.01). MicroSPECT/CT imaged HER2-overexpressing MDA-MB-361 tumors but not MDA-MB-231 tumors with low HER2 expression. Tumor uptake was 5.2-fold significantly greater at 24 h p.i. in MDA-MB-361 than MDA-MB-231 tumors (3.2 ± 0.1 %ID/g vs. 0.8 ± 0.1 %ID/g; P < 0.05).

CONCLUSIONS

MicroSPECT/CT with [^99mTc]His₆-pertuzumab Fab imaged tumors in NOD/SCID mice that exhibited intermediate or high HER2 expression, but not tumors with low HER2. [^99mTc]His₆-pertuzumab Fab is promising for SPECT imaging of tumor HER2 expression.

Auger electrons for cancer therapy - a review

Background

Auger electrons (AEs) are very low energy electrons that are emitted by radionuclides that decay by electron capture (e.g. ¹¹¹In, ⁶⁷Ga, ^99mTc, ^195mPt, ¹²⁵I and ¹²³I). This energy is deposited over nanometre-micrometre distances, resulting in high linear energy transfer (LET) that is potent for causing lethal damage in cancer cells. Thus, AE-emitting radiotherapeutic agents have great potential for treatment of cancer. In this review, we describe the radiobiological properties of AEs, their radiation dosimetry, radiolabelling methods, and preclinical and clinical studies that have been performed to investigate AEs for cancer treatment.

Results

AEs are most lethal to cancer cells when emitted near the cell nucleus and especially when incorporated into DNA (e.g. ¹²⁵I-IUdR). AEs cause DNA damage both directly and indirectly via water radiolysis. AEs can also kill targeted cancer cells by damaging the cell membrane, and kill non-targeted cells through a cross-dose or bystander effect. The radiation dosimetry of AEs considers both organ doses and cellular doses. The Medical Internal Radiation Dose (MIRD) schema may be applied. Radiolabelling methods for complexing AE-emitters to biomolecules (antibodies and peptides) and nanoparticles include radioiodination (¹²⁵I and ¹²³I) or radiometal chelation (¹¹¹In, ⁶⁷Ga, ^99mTc). Cancer cells exposed in vitro to AE-emitting radiotherapeutic agents exhibit decreased clonogenic survival correlated at least in part with unrepaired DNA double-strand breaks (DSBs) detected by immunofluorescence for γH2AX, and chromosomal aberrations. Preclinical studies of AE-emitting radiotherapeutic agents have shown strong tumour growth inhibition in vivo in tumour xenograft mouse models. Minimal normal tissue toxicity was found due to the restricted toxicity of AEs mostly on tumour cells targeted by the radiotherapeutic agents. Clinical studies of AEs for cancer treatment have been limited but some encouraging results were obtained in early studies using ¹¹¹In-DTPA-octreotide and ¹²⁵I-IUdR, in which tumour remissions were achieved in several patients at administered amounts that caused low normal tissue toxicity, as well as promising improvements in the survival of glioblastoma patients with ¹²⁵I-mAb 425, with minimal normal tissue toxicity.

Conclusions

Proof-of-principle for AE radiotherapy of cancer has been shown preclinically, and clinically in a limited number of studies. The recent introduction of many biologically-targeted therapies for cancer creates new opportunities to design novel AE-emitting agents for cancer treatment. Pierre Auger did not conceive of the application of AEs for targeted cancer treatment, but this is a tremendously exciting future that we and many other scientists in this field envision.

MicroSPECT/CT Imaging of Cell-Line and Patient-Derived EGFR-Positive Tumor Xenografts in Mice with Panitumumab Fab Modified with Hexahistidine Peptides To Enable Labeling with 99mTc(I) Tricarbonyl Complex

We aimed to investigate the feasibility of conjugating synthetic hexahistidine peptides (His₆) peptides to panitumumab Fab (PmFab) to enable labeling with [^99mTc(H₂O)₃(CO)₃]⁺ complex and study these radioimmunoconjugates for imaging EGFR-overexpressing tumor xenografts in mice by microSPECT/CT. Fab were reacted with a 10-fold excess of sulfo-SMCC to introduce maleimide functional groups for reaction with the terminal thiol on peptides [CGYGGHHHHHH] that harbored the His₆ motif. Modification of Fab with His₆ peptides was assessed by SDS-PAGE/Western blot, and the number of His₆ peptides introduced was quantified by a radiometric assay incorporating ¹²³I-labeled peptides into the conjugation reaction. Radiolabeling was achieved by incubation of PmFab-His₆ in PBS, pH 7.0, with [^99mTc(H₂O)₃(CO)₃]⁺ in a 1.4 MBq/μg ratio. The complex was prepared by adding [^99mTcO₄]^- to an Isolink kit (Paul Scherrer Institute). Immunoreactivity was assessed in a direct (saturation) binding assay using MDA-MB-468 human triple-negative breast cancer (TNBC) cells. Tumor and normal tissue uptake and imaging properties of ^99mTc-PmFab-His₆ (70 μg; 35-40 MBq) injected i.v. (tail vein) were compared to irrelevant ^99mTc-Fab 3913 in NOD/SCID mice engrafted subcutaneously (s.c.) with EGFR-overexpressing MDA-MB-468 or PANC-1 human pancreatic ductal carcinoma (PDCa) cell-line derived xenografts (CLX) at 4 and 24 h post injection (p.i.). In addition, tumor imaging studies were performed with ^99mTc-PmFab-His₆ in mice with patient-derived tumor xenografts (PDX) of TNBC, PDCa, and head and neck squamous cell carcinoma (HNSCC). Biodistribution studies in nontumor bearing Balb/c mice were performed to project the radiation absorbed doses for imaging studies in humans with ^99mTc-PmFab-His₆. PmFab was derivatized with 0.80 ± 0.03 His₆ peptides. Western blot and SDS-PAGE confirmed the presence of His₆ peptides. ^99mTc-PmFab-His₆ was labeled to high radiochemical purity (≥95%), and the K_d for binding to EGFR on MDA-MB-468 cells was 5.5 ± 0.4 × 10^-8 mol/L. Tumor uptake of ^99mTc-PmFab-His₆ at 24 h p.i. was significantly (P < 0.05) higher than irrelevant ^99mTc-Fab 3913 in mice with MDA-MB-468 tumors (14.9 ± 3.1%ID/g vs 3.0 ± 0.9%ID/g) and in mice with PANC-1 tumors (5.6 ± 0.6 vs 0.5 ± 0.1%ID/g). In mice implanted orthotopically in the pancreas with the same PDCa PDX, tumor uptake at 24 h p.i. was 4.2 ± 0.2%ID/g. Locoregional metastases of these PDCa tumors in the peritoneum exhibited slightly and significantly lower uptake than the primary tumors (3.1 ± 0.3 vs 4.2 ± 0.3%ID/g; P = 0.02). In mice implanted with different TNBC or HNSCC PDX, tumor uptake at 24 h p.i. was variable and ranged from 3.7 to 11.4%ID/g and 3.8-14.5%ID/g, respectively. MicroSPECT/CT visualized all CLX and PDX tumor xenografts at 4 and 24 h p.i. Dosimetry estimates revealed that in humans, the whole body dose from administration of 740-1110 MBq of ^99mTc-PmFab-His₆ would be 2-3 mSv, which is less than for a ^99mTc-medronate bone scan (4 mSv).

Synthesis of Chitosan-Alginate Microcapsule Membranes

A polysaccharide, chitosan, was chemically modified to form a polyelectrolyte complex membrane with calcium alginate beads. A key factor in membrane for mation was found to be the viscosity average molecular weight (M v) of the chitosan. While unmodified chitosan (Mv = 12.1 x 105) formed thin and weak microcapsule membranes, when the Mv of the chitosan was reduced to 2.4 x 105, the polymer exhibited optimum membrane forming characteristics in terms of capsule strength and flexibility. The degree of deacetylation of chi tosan varied from 94.3% for the unmodified polymer to 93.2% for chitosan of Mv = 1.6 × 105. A substitution reaction sequence was developed in an attempt to modify the pendant amine of the practical grade polysaccharide. Reactive groups were coupled to the chitosan main chain following a two-step process; activation with a bromoacetyl halide and termination with a diamine [(NH2 (CH2)nNH2)] or methyl containing amine compound. Initial studies indicated that thin capsule membranes formed regardless of application of reaction se quence, distance of reactive groups from the main chain, or type of reactive group inserted. The permeability of the chitosan-alginate capsules was assessed, with various diffusing proteins. Membranes formed with chitosan Mv =0.5 × 106 excluded beta amylase, suggesting a membrane molecular weight cut-off of approximately 200,000.

Gaulin homogenization: a mechanistic study

Free radical-based oxidation has been detected in the normal operating regime of the Gaulin homogenizer, demonstrating that cavitation occurs in this important industrial bioprocessing equipment. Free radical generation is suppressed by imposition of back pressure, proving that such cavitation occurs in the impingement section. The calculated value of the cavitation number is consistent with submerged jet cavitation, wherein a high-speed jet exiting from the valve gap accelerates fluid in the impingement region, creating the vacuum conditions for cavitation. Using polysaccharides as a model shear-sensitive compound, their breakage pattern in the homogenizer was characterized by molecular size and polydispersity and compared to those of fluid shear flows in capillary tubes and cavitating flow from a sonic horn. The results indicate that breakage occurs primarily by fluid shear, although a contribution by cavitation is also apparent when back pressure is applied. Because biological molecules can readily react with free radicals and the alterations caused thereby are subtle in nature, a thorough evaluation of the impact of free radicals in upstream homogenization is warranted.

Isolated straight sinus thrombosis: clinical and neuroradiologic correlates

A rare case of straight sinus thrombosis in a 36-year-old female with sudden onset of status migrainosus is presented. This condition was demonstrated by a linear density in the midline on a noncontrast computed tomography scan, as a filling defect at the location of straight sinus on magnetic resonance imaging, and by the inability to visualize blood flow in the straight sinus on magnetic resonance venography, with a similar demonstration on a 4-vessel digital subtraction angiography.

Herpes zoster polyradiculopathy

Herpes zoster infection, resulting from reactivation of the dormant varicella zoster virus in the dorsal root ganglia, usually causes a painful dermatomal vesicular rash. Rarely, associated peripheral motor weakness is present, the mechanism of which is unclear. Three patients are reported who had focal limb muscle weakness associated with zoster infection. Physical and occupational therapy played a key role in motor function recovery of the patients, yet emphasis on the rehabilitation of postherpetic motor weakness is lacking in the literature. Physiatrists evaluating patients with limb muscle weakness following herpes zoster infection should be alert to this condition. The clinical syndrome of herpes zoster radiculopathy and the rehabilitation of these patients are discussed.

Tethered thoracic cord resulting from spinal cord herniation

Tethered cord syndrome (TCS) usually involves tethering of the lower cord at the conus medullaris from dural abnormalities, but may occur after spinal cord herniation. A tethered thoracic spinal cord is rare. We present an unusual case of a 30-year-old woman with a history of myelopathy presumed to be secondary to T6 cord compression resulting from T6-T8 arachnoid cyst. She continued to deteriorate after partial excision of the cyst. Repeat magnetic resonance imaging suggested recurrence of the presumed arachnoid cyst with cord compression and showed tethering at T6-T8. Surgical exploration revealed myelocele with cord herniation through the anterior thoracic dura. Pathologic diagnosis showed neural tissue with gliosis. After physical therapy treatments, the patient had increased lower extremity strength, ambulated with a cane, and regained some bladder control. Progressive myelopathy may represent tethering of the cord resulting from cord herniation. Early recognition of TCS, even in patients with minimal neurologic deficits, could prevent progressive disability.

Balloon-assisted coil placement in wide-necked aneurysms. Technical note

Saccular intracranial aneurysms are a common and often fatal lesion. Whereas surgical treatment of these aneurysms continues to be the gold standard of care, certain situations arise for which surgery may not be the best option. In some of these cases, electrolytically detachable coils have been proven to provide outcomes superior to those seen for medical management alone. The authors present two cases of ophthalmic artery aneurysms that would not hold the Guglielmi detachable coils on the initial attempt. One aneurysm was 7 mm and one 4 mm, both with wide necks relative to the aneurysm sac. By using a balloon-assisted technique and blocking the parent artery with a nondetachable balloon, the coils could be safely placed in these aneurysms without herniation when the balloon was deflated. Both patients exhibited embolic symptoms after the procedure, one with a mild but permanent deficit. Although this technique requires manipulation of a second microcatheter and balloon, which increases its technical difficulties and is a higher risk procedure than standard coil placement, it has utility in patients who are not candidates for surgery.

Selective language aphasia from herpes simplex encephalitis

We report the case of a 16-year-old right-handed Chinese/English bilingual patient who developed herpes simplex encephalitis involving the left temporal lobe, with resultant aphasia. His native language was Mandarin, but he had received extensive training in English for 6 years after moving to the United States and was fluent in English. One week after admission, he could not speak, comprehend, repeat, name, read, or write in English, but he had relative preservation of most of these facilities in Mandarin. He could not write in Mandarin, and his syntax was simplified. Two months later, along with intensive bilingual speech therapy, his reading, writing, and naming in English had almost recovered.

Upper limb reflex sympathetic dystrophy associated with occult malignancy

Reflex sympathetic dystrophy, characterized by pain, swelling, vasomotor instability, and trophic changes in an extremity, has been infrequently described in patients with occult malignancy. Two cases of reflex sympathetic dystrophy associated with local tumor involvement are reported. Both patients had a history of cancer in clinical remission. Despite aggressive physical therapy measures, the patients' symptoms persisted. Workup of the first patient found an apical paravertebral mass in the lung; biopsy revealed recurrent breast carcinoma. In the second case, workup found an axillary mass contiguous with the lower brachial plexus. Biopsy revealed lymphoma, a second primary malignancy. In both cases, medical treatment of the tumor was instituted, with consequent improvement of hand and shoulder function. Both patients required prolonged hospitalization and multiple procedures that might have been avoided if malignancy had been suspected. Spontaneous development of reflex sympathetic dystrophy in patients with a history of cancer should alert the physician to the possibility of occult malignancy.

Omental transposition in chronic spinal cord injury

The results of omental transposition in chronic spinal cord injury have been reported in 160 patients operated upon in the United States, Great Britain, China, Japan, India and Mexico, with detailed outcomes reported in few studies. Recovery of function to a greater degree than expected by natural history has been reported. In this series, 15 patients with chronic traumatic spinal cord injury (> 1.5 years from injury) underwent transposition of pedicled omentum to the area of the spinal cord injury. Of the first series of four patients who were operated upon in 1988, one died, one was lost to follow-up and two were followed with sequential neurological examinations and Magnetic Resonance Imaging (MRI) scans preoperatively, at 1 year post injury and 4 1/2 years post injury. Another 11 patients were operated in 1992 and underwent detailed neurological and neurophysiological examinations and had MRI scans preoperatively and every 4 months for at least 1 year after surgery. All patients completed a detailed self-report form. Of the total of 13 operated patients in both series followed for 1-4 1/2 years, six reported some enhanced function at 1 year and five of these felt the changes justified surgery primarily because of improved truncal control and decreased spasticity. MRI scans showed enlargement of the spinal cord as compared to preoperative scans in seven patients. Increased T2 signal intensity of the spinal cord was found by 1 year after surgery in eight of 13 operated patients. Neurophysiological examinations of 11 patients in the second series agreed with self-reports of increases or decreases in spasticity (r = 0.65, P < 0.03). Somatosensory evoked potentials and motor evoked potentials at 4 month intervals up to 1 year in these patients showed no change after surgery. Neurological testing, using the American Spinal Injury Association (ASIA) and International Medical Society of Paraplegia (IMSOP) international scoring standards, failed to show any significant changes when the 1-year post operative examination was compared to the first preoperative examination except for decreased sensory function after surgery which approached statistical significance. When the 11 patients in the second series were compared to eight non-operated matched patients, followed for a similar length of time, no significant differences were found. Complications encountered in the operated patients from both series included one postoperative death from a pulmonary embolus, one postoperative pneumonia, three chronic subcutaneous cerebrospinal fluid (CSF) fistulae requiring wound revision, and one patient who developed biceps and wrist extensor weakness bilaterally requiring graft removal. We conclude that the omental graft remains viable over time and this operation can induce anatomical changes in the spinal cord as judged by MRI. Some patients reported subjective improvement but this was not supported by objective testing. We, therefore, find no justification for further clinical trials of this procedure in patients who have complete or sensory incomplete lesions. Further testing in motor incomplete patients would seem appropriate only with compelling supportive data.

Lumbosacral radiculopathy secondary to L5 metastatic melanoma of unknown primary

Lumbosacral radiculopathy secondary to spinal malignancy is rare. Spinal melanoma without cutaneous manifestations is even more unusual. We present the case of a 45-year-old physician with a history of degenerative disease of lumbar spine and chronic back pain who presented with increasing back pain with right radiculopathy despite conservative management for 6 months. Computed tomography showed a destructive lesion of the L5 vertebral body. Results from a biopsy guided by computed tomography suggested neoplasm of unknown origin. The patient underwent anterior vertebrectomy with instrumentation and fusion. Surgical pathology study results showed metastatic melanoma of unknown primary. The patient had no cutaneous manifestation of the disease. This is the first reported case of radiculopathy due to melanoma metastatic to the lumbar spine. In view of the atypical presentation of our patient's malignancy, we emphasize the importance of including malignancy of lumbar spine in the differential diagnosis of progressive lower back pain with radiculopathy.

Neurosarcoidosis of the conus medullaris and cauda equina presenting as paraparesis: case report and literature review

Sarcoidosis is a multi-system, non-caseating granulomatous disease of unknown etiology. Although spinal cord involvement is rare, it may cause severe neurological complications. We report the case of a 52-year-old woman who developed low back pain and a progressive flaccid paraparesis whose investigations revealed pulmonary and spinal sarcoidosis. To our knowledge, this is the first reported case of sarcoidosis of the conus medullaris and cauda equina diagnosed by an unusual enhancement pattern observed on magnetic resonance imaging with gadolinium. Biopsy of the lumbar nerve roots and of the lung revealed a non-caseating granuloma. Treatment with steroids and intensive rehabilitation resulted in remarkable functional improvement. Although rare, sarcoidosis of the conus medullaris and cauda equina should be considered in the differential diagnosis of flaccid paraparesis, particularly in patients with non-diagnostic evaluations.

Severe polyneuropathy: initial manifestation of Castleman's disease associated with POEMS syndrome

Castleman's disease is a rare clinicopathological entity characterized by multicentric angiofollicular lymph node hyperplasia. Peripheral neuropathy has infrequently been described in patients with Castleman's disease. A patient is described who presented initially with severe painful sensorimotor polyneuropathy of his lower limbs diagnosed as a plasma cell variant of Castleman's disease associated with features of POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin change). The patient was treated with plasmapheresis, immunosuppressive agents, and intensive rehabilitation. His functional status improved from being wheelchair bound to ambulating independently with crutches. Clinicians should be alert to the relationship of Castleman's disease and mixed polyneuropathy because physical improvement is possible with treatment. Also, the evaluation of patients presenting with peripheral neuropathy of unknown etiology and lymphadenopathy should include lymph node biopsy to rule out Castleman's disease.

Embolization of a mesenteric artery aneurysm: case report

Gelfoam embolization of a jejunal artery branch aneurysm was performed using an open-ended guidewire. The outflow vessel was embolized first, followed by occlusion of the feeding artery, to exclude collateral filling.