Higher Triad Risk Scores Are Associated With Increased Risk for Trabecular-Rich Bone Stress Injuries in Female Runners

OBJECTIVE

Bone stress injuries (BSIs) in trabecular-rich bone are associated with greater biological risk factors compared with cortical-rich bone. We hypothesized that female runners with high Female Athlete Triad (Triad)-related risk would be at greater risk for trabecular-rich BSIs than runners with low Triad-related risk.

DESIGN

Prospective cohort study.

SETTING

Two NCAA institutions.

PARTICIPANTS

Female runners were followed prospectively for up to 5 years.

INTERVENTION

The intervention consisted of team nutrition presentations focused on optimizing energy availability plus individualized nutrition sessions. Triad Cumulative Risk Assessment (CRA) categories were assigned yearly based on low-energy availability, menstrual status, age of menarche, low body mass index, low bone mineral density, and prior BSI.

MAIN OUTCOME MEASURES

The outcome was the annual incidence of trabecular- and cortical-rich BSI. Generalized Estimating Equations (GEE, to account for the correlated nature of the observations) with a Poisson distribution and log link were used for statistical modeling.

RESULTS

Cortical-rich BSI rates were higher than trabecular-rich BSI rates (0.32 vs 0.13 events per person-year). Female runners with high Triad-related risk had a significantly higher incidence rate ratio of trabecular-rich BSI (RR: 4.40, P = 0.025) and cortical-rich BSI (RR: 2.87, P = 0.025) than women with low Triad-related risk. Each 1-point increase in Triad CRA score was associated with a significant 26% increased risk of trabecular-rich BSI ( P = 0.0007) and a nonsignificant 14% increased risk of cortical-rich BSI ( P = 0.054).

CONCLUSIONS

Increased Triad CRA scores were strongly associated with increased risk for trabecular-rich BSI. Incorporating Triad CRA scores in clinical care could guide BSI prevention.

Neurogenic Thoracic Outlet Syndrome in Division 1 Collegiate Athletes: Presentation, Diagnosis, and Treatment

OBJECTIVE

Athletes who engage in repetitive upper-extremity exercise are susceptible to neurogenic thoracic outlet syndrome (nTOS). We sought to identify typical presenting symptoms and common findings on diagnostic workup, in addition to evaluating rates of return to play following various treatment interventions.

DESIGN

Retrospective chart review.

SETTING

Single institution.

PARTICIPANTS

Medical records of Division 1 athletes containing the diagnosis of nTOS between the years 2000 and 2020 were identified. Athletes with arterial or venous thoracic outlet syndrome were excluded.

INDEPENDENT VARIABLES

Demographics, sport, participation status, clinical presentation, physical examination findings, diagnostic workup, and treatments provided.

MAIN OUTCOME MEASURES

Rate of return to play (RTP) to collegiate athletics.

RESULTS

Twenty-three female and 13 male athletes were diagnosed and treated for nTOS. Digit plethysmography showed diminished or obliterated waveforms with provocative maneuvers in 23 of 25 athletes. Forty-two percent were able to continue competing despite symptoms. Of the athletes who were initially unable to compete, 12% returned to full competition after physical therapy alone, 42% of those remaining were able to RTP after botulinum toxin injection, and an additional 42% of the remaining athletes RTP after thoracic outlet decompression surgery.

CONCLUSIONS

Many athletes diagnosed with nTOS will be able to continue competing despite symptoms. Digit plethysmography is a sensitive diagnostic tool for nTOS to document anatomical compression at the thoracic inlet. Botulinum toxin injection had a significant positive effect on symptoms and a high rate of RTP (42%), allowing numerous athletes to avoid surgery and its prolonged recovery and associated risks.

CLINICAL RELEVANCE

This study demonstrates that botulinum toxin injection had a high rate of return to full competition in elite athletes without the risks and recovery needed for surgical intervention, suggesting that this may be a good intervention especially among elite athletes who only experience symptoms with sport-related activities.

Healthy Runner Project: a 7-year, multisite nutrition education intervention to reduce bone stress injury incidence in collegiate distance runners

Objectives

We evaluated the effect of a nutrition education intervention on bone stress injury (BSI) incidence among female distance runners at two NCAA Division I institutions.

Methods

Historical BSI rates were measured retrospectively (2010-2013); runners were then followed prospectively in pilot (2013-2016) and intervention (2016-2020) phases. The primary aim was to compare BSI rates in the historical and intervention phases. Pilot phase data are included only for descriptive purposes. The intervention comprised team nutrition presentations focused on optimising energy availability plus individualised nutrition sessions for runners with elevated Female Athlete Triad risk. Annual BSI rates were calculated using a generalised estimating equation Poisson regression model adjusted for age and institution. Post hoc analyses were stratified by institution and BSI type (trabecular-rich or cortical-rich).

Results

The historical phase included 56 runners and 90.2 person-years; the intervention phase included 78 runners and 137.3 person-years. Overall BSI rates were not reduced from the historical (0.52 events per person-year) to the intervention (0.43 events per person-year) phase. Post hoc analyses demonstrated trabecular-rich BSI rates dropped significantly from 0.18 to 0.10 events per person-year from the historical to intervention phase (p=0.047). There was a significant interaction between phase and institution (p=0.009). At Institution 1, the overall BSI rate dropped from 0.63 to 0.27 events per person-year from the historical to intervention phase (p=0.041), whereas no decline was observed at Institution 2.

Conclusion

Our findings suggest that a nutrition intervention emphasising energy availability may preferentially impact trabecular-rich BSI and depend on team environment, culture and resources.

Prevalence of Female and Male Athlete Triad Risk Factors in Ultramarathon Runners

OBJECTIVE

To identify the prevalence of male and female athlete triad risk factors in ultramarathon runners and explore associations between sex hormones and bone mineral density (BMD).

DESIGN

Multiyear cross-sectional study.

SETTING

One hundred-mile ultramarathon.

PARTICIPANTS

Competing runners were recruited in 2018 and 2019.

ASSESSMENT OF RISK FACTORS

Participants completed a survey assessing eating behaviors, menstrual history, and injury history; dual-energy x-ray absorptiometry for BMD; and laboratory evaluation of sex hormones, vitamin D, and ferritin (2019 cohort only).

MAIN OUTCOME MEASURE

A Triad Cumulative Risk Assessment Score was calculated for each participant.

RESULTS

One hundred twenty-three runners participated (83 males and 40 females, mean age 46.2 and 41.8 years, respectively). 44.5% of men and 62.5% of women had elevated risk for disordered eating. 37.5% of women reported a history of bone stress injury (BSI) and 16.7% had BMD Z scores <-1.0. 20.5% of men had a history of BSI and 30.1% had Z-scores <-1.0. Low body mass index (BMI) (<18.5 kg/m 2 ) was seen in 15% of women and no men. The Triad Cumulative Risk Assessment classified 61.1% of women and 29.2% of men as moderate risk and 5.6% of both men and women as high risk.

CONCLUSIONS

Our study is the first to measure BMD in both male and female ultramarathon runners. Our male population had a higher prevalence of low BMD than the general population; females were more likely to report history of BSI. Risk of disordered eating was elevated among our participants but was not associated with either low BMD or low BMI.

Pertuzumab for the treatment of patients with previously untreated HER2-positive metastatic breast cancer

Pertuzumab is a humanized monoclonal antibody directed at the dimerization domain of the receptor tyrosine-protein kinase erbB-2 (HER2) receptor. It possesses a unique and complimentary mechanism of action compared to trastuzumab, which has historically been the cornerstone of therapy for HER2-amplified breast cancer. Clinical trials demonstrate improved outcomes, with minimal increases in toxicity with the addition of pertuzumab to trastuzumab in patients with HER2-positive metastatic breast cancer, indicating the advantage of dual HER2 receptor blockade. Pertuzumab is approved as first-line therapy in combination with trastuzumab and docetaxel for HER2-positive metastatic breast cancer, with future opportunities to investigate its efficacy in other stages of breast cancer, as well as in the treatment of other malignancies.

Incidence and risk of central nervous system metastases as site of first recurrence in patients with HER2-positive breast cancer treated with adjuvant trastuzumab

BACKGROUND

Central nervous system (CNS) disease as the site of first relapse after exposure to adjuvant trastuzumab has been reported. We carried out comprehensive meta-analysis to determine the risk of CNS metastases as the first site of recurrence in patients with HER2-positive breast cancer who received adjuvant trastuzumab.

METHODS

Eligible studies include randomized trials of adjuvant trastuzumab administered for 1 year to patients with HER2-positive breast cancer who reported CNS metastases as first site of disease recurrence. Statistical analyses were conducted to calculate the incidence, relative risk (RR), and 95% confidence intervals (CIs) using fixed-effects inverse variance and random-effects models.

RESULTS

A total of 9020 patients were included. The incidence of CNS metastases as first site of disease recurrence in HER2-positive patients receiving adjuvant trastuzumab was 2.56% (95% CI 2.07% to 3.01%) compared with 1.94% (95% CI 1.54% to 2.38%) in HER2-positive patients who did not receive adjuvant trastuzumab. The RR of the CNS as first site of relapse in trastuzumab-treated patients was 1.35 (95% CI 1.02-1.78, P = 0.038) compared with control arms without trastuzumab therapy. The ratio of CNS metastases to total number of recurrence events was 16.94% (95% CI 10.85% to 24.07%) and 8.33% (95% CI 6.49% to 10.86%) for the trastuzumab-treated and control groups, respectively. No statistically significant differences were found based on trastuzumab schedule or median follow-up time. No evidence of publication bias was observed.

CONCLUSIONS

Adjuvant trastuzumab is associated with a significant increased risk of CNS metastases as the site of first recurrence in HER2-positive breast cancer patients.

Abstract P5-18-17: Impact of compliance with National Comprehensive Cancer Network guidelines on adjuvant trastuzumab administration for patients with HER2-positive breast cancer

Background: The National Comprehensive Cancer Network (NCCN) breast cancer guidelines recommend trastuzumab as a component of adjuvant therapy for patients with stage I-III HER2-positive breast cancer. Reasons for noncompliance with adjuvant trastuzumab therapy and the impact of noncompliance with national guidelines are unknown.

Methods: We retrospectively identified 331 patients with stage I-III HER2 -positive breast cancer treated at the Ohio State University James Cancer Hospital 2005–2011 who were eligible for adjuvant trastuzumab. Medical records were reviewed to obtain age at diagnosis, race, co-morbidity score, stage, hormone positivity, type of therapy administered, date of disease recurrence, vital status and date of last follow up. Available clinician-documented reasons for not administering adjuvant trastuzumab were also recorded. Multivariate logistic regression modeling was used to examine the effect of these variables on completion of 1 year of adjuvant trastuzumab. Cox regression modeling was used to estimate the effect of completing 1 year of trastuzumab on disease-free and overall survival, respectively.

Results: Median follow up was 39.9 months (range 12.0–85.1). Of the 331 patients, the majority of (289; 87%) received at least 1 dose of trastuzumab while 251 (76%) patients completed the recommended 1 year of trastuzumab therapy. In multivariate modeling, age ≥ 70 years (Odds Ratio 0.18, 95% CI 0.07 to 0.47; p &lt; 0.0001) and stage I disease (Odds Ratio 0.34, 95% CI 0.18 to 0.63; p = 0.001) were significant predictors of failure to receive 1 year of adjuvant trastuzumab. Race, hormone status and co-morbidity score were not predictors for completing 1 year of adjuvant trastuzumab. Of the 80 patients who did not complete 1 year of trastuzumab, clinician-documented reasons for noncompliance were available for all women. Reasons cited by treating physicians for either not initiating or completing 1 year of trastuzumab included small tumor size (24; 30%), baseline cardiac dysfunction (19; 24%), medication toxicity (4; 5%), patient refusal (13; 16%), advanced age (5; 6%), development of metastatic disease during adjuvant therapy (5; 6%) or other (10; 13%). Patients who did not complete 1 year of adjuvant trastuzumab had a significantly increased risk of death (HR 6.67; 95% CI 2.72 to 16.36; p &lt; 0.0001) and risk of disease recurrence (HR 3.74; 95% CI 1.88 to 7.46; p &lt; 0.0001) after adjusting for age, stage and co-morbidity score.

Conclusion: Age ≥ 70 years and stage I disease are predictors of noncompliance with NCCN guidelines recommending administration of adjuvant trastuzumab therapy for one year. Failure to complete one year of adjuvant trastuzumab is significantly associated with disease recurrence and worse overall survival in patients with stage I-III HER2-amplified breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-18-17.

Abstract P2-11-07: Endothelial progenitor cells as novel markers of anthracycline induced cardiac injury

Background: Anthracyclines including doxorubicin (DOX) cause myocardial damage that manifests as either subclinical decrements of left ventricular ejection function (LVEF) or overt cardiomyopathy. LVEF changes and cardiac risk factors are insufficient predictors of future DOX cardiotoxicity. Bone marrow derived endothelial progenitor cells (EPCs) are mobilized and are homed to sites of myocardial injury to help with repair of damaged myocardium. We hypothesized that EPC levels would be indicative of early DOX cardiotoxicity. Hence, we prospectively collected serial blood samples to evaluate functional EPCs, Troponin I (Ti) and B-natriuretic peptide (BNP), in patients (pts) receiving DOX-based chemotherapy.

Methods: Eligible pts were initiating adjuvant DOX for early stage breast cancer. Pts underwent cardiac magnetic resonance (CMR), Ti, BNP, and EPC at baseline, after 1 cycle of DOX, and after completion of DOX. CD133+ progenitor cells were isolated from the peripheral blood mononuclear cells (PBMC) using AutoMACS (automated magnetic cell sorting, Miltenyi Biotech). In vitro colony forming unit (CFU) assay was performed for isolated CD133+ progenitor cells on MethoCult (Stemcell Technology). After 8 days of culture, EPC colonies were counted using a two-step image analysis algorithm. Repeated measures analysis of variance modeled changes in cardiac markers over time. Logistic regression was used to correlate variables with abnormal Ti.

Results: Forty two women were enrolled. The average age was 52 years (range 33–68) and stage distribution was I (14%), II (58%) and III (28%). All but one patient received peg-fligrastim after DOX. Thirty six pts had EPC/cardiac biomarkers and twenty nine pts had CMRs at all three time points. LVEF decreased 1.6% following completion of DOX (95% CI: −3.8 to 0.6, p = 0.16). There was a non-linear trend in EPCs over time (p = 0.05), with an initial increase followed by a decrease, with average values of 59 (95% CI: 50–70), 65 (95% CI: 55–75), and 50 (95% CI: 40–60), respectively, across the three time points. By the end of treatment, 54% (95% CI: 0.37–0.71) of women had abnormal troponins (median: 0.03, range: 0.02 to 0.17). Variables associated with abnormal troponins included lower baseline EPCs (p = 0.095), older age (p = 0.075) and initial increase in BNP post cycle 1 (p &lt; 0.03). In a multivariable model, age (p = 0.04) and BNP (p = 0.04) were independent prognostic factors for abnormal troponins, where the odds of abnormal troponins was 65% higher for every 5-year increase in age (OR = 1.65, 95% CI: 1.02–2.66) and 58% higher for every 1.5-fold increase in BNP (OR = 1.58, 95% CI: 1.01–2.46). Baseline EPC did not remain in the final model with p = 0.12.

Conclusions: DOX was well-tolerated with no significant changes in LVEF as measured by serials CMRs. Older age and increased BNP were independent prognostic factors for rise in Ti. We observed an initial increase of EPCs with DOX exposure followed by a decrease after the end of treatment. Although not statistically significant, lower EPCs at baseline, corresponding to lower cardiac reserve, were correlated with abnormal Ti. This is the first study reporting an intriguing association of EPCs with traditional cardiac biomarkers during DOX chemotherapy. Funded by R21 CA143787-02.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-11-07.

Responses to subsequent anti-HER2 therapy after treatment with trastuzumab-DM1 in women with HER2-positive metastatic breast cancer

BACKGROUND

Women with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) can respond to multiple lines of anti-HER2 therapy. It is unknown whether these patients will derive further clinical benefit following treatment with trastuzumab-MCC-DM1 (T-DM1).

PATIENTS AND METHODS

We retrospectively identified HER2-positive MBC patients treated with T-DM1 and characterized outcomes during subsequent lines of anti-HER2 therapy. Response was determined by a blinded radiology review. Time-dependent analyses were carried out using Kaplan-Meier estimates.

RESULTS

We identified 23 patients treated with single-agent T-DM1 and report on the 20 patients who discontinued protocol therapy. All patients received trastuzumab-based metastatic therapy before initiation of T-DM1 [median 7 regimens (range 3-14)]. Of these 20 patients, 75% (15 of 20) received further therapy with or without anti-HER2 agents after discontinuing T-DM1. Partial response to either first- or second-subsequent line(s) of therapy was seen in 5 of 15 (33%) treated patients, including 33% (4 of 12) who received a regimen containing trastuzumab and/or lapatinib. Median durations of therapy to first- and second-subsequent regimens after T-DM1 were 5.5 and 6.4 months, respectively.

CONCLUSIONS

In heavily pretreated HER2-positive MBC patients, prior exposure to T-DM1 does not exhaust the potential benefit of ongoing anti-HER2 therapy with trastuzumab- and/or lapatinib-based regimens.

PD05-07: Prospective Validation and Characterization of HER2 Positive Circulating Tumor Cells in Patients with HER2 Negative Metastatic Breast Cancer

Background: Circulating tumor cells (CTCs) with evidence of HER2 amplification can occur in patients (pts) with clinically HER2 negative metastatic breast cancer. While these findings potentially have profound implications for CTCs as a biomarker for treatment, prospective validation and characterization of this subgroup is necessary.

Methods: We created a prospective cohort of pts with metastatic breast cancer that were HER2 negative by IHC and/or FISH on all available primary and metastatic biopsies. Blood samples were collected at study entry and then again at ≥ 3 weeks if available. CTCs were enumerated by a modification of the Veridex CellSearch Profile kit. FISH was performed on each CTC sample and reported as positive if the HER2/CEP17 ratio was ≥ 2.0. Analyses are descriptive.

Results: 66 pts were consented for study and this report includes the 65 pts with detectable CTCs. Median number of CTCs was 226 (range 112 to &gt; 3000). At initial testing, 23 pts (35%) had HER2 positive CTCs, median HER2:CEP17 ratio of 3.4. 50% (11 of 22) of the pts with lobular or ductal/lobular histology had HER2 amplified CTCs, compared to only 27% (10 of 36) of patients with ductal histology. Women with ER positive disease had HER2 positive CTCs in 40% of cases (20 of 49) compared to 19% of ER negative pts (3 of 16). To assess concordance of HER2 amplification of CTCs over time, 34 pts consented to be retested at a median 5.9 weeks after initial screening (range 3.3 - 17 weeks) and all but 1 had detectable CTCs. Baseline characteristics of these 34 pts were similar to the original population, with HER2 amplified CTCs detected in 35% (12 of 34) pts at initial screening. HER2 positive CTCs were concordant at time of retesting in 83% (10 of 12) pts; the 2 women with discordant CTCs were receiving HER2 directed therapy. Of the pts with HER2 negative CTCs at initial screening, 81% (17 of 21) continued to have HER2 negative CTCs at time of retesting.

Conclusion: We observed a higher prevalence of HER2 positive CTCs among pts with ER positive disease and evidence of lobular histology. The presence of HER2 positive CTCs is concordant over time in the majority of pts. The functional significance of HER2 positive CTCs in patients with clinically HER2 negative breast cancer will be tested in a prospective study with HER2−directed therapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD05-07.

Abstract P3-14-08: Responses to Subsequent Anti-HER2 Therapy after Treatment with Trastuzumab-DM1 in Women with HER2-Positive Metastatic Breast Cancer

Background: Women with HER2-positive metastatic breast cancer (MBC) can have clinical responses to multiple lines of anti-HER2 therapy. However, it is unknown whether these patients will derive further clinical benefit following treatment with the novel antibody-drug conjugate trastuzumab-MCC-DM1 (T-DM1), which has significant activity in trastuzumab-refractory breast cancer.

Methods: We retrospectively identified patients treated with T-DM1 monotherapy on clinical trials for HER2-positive MBC at Dana-Farber Cancer Institute and characterized clinical outcomes during subsequent lines of anti-HER2 therapy. Response was determined by an independent and blinded radiology review using modified RECIST 1.1 criteria without confirmatory scans; patients without radiologic assessment were considered non-responders. Duration of therapy was defined from initiation of therapy until treatment discontinuation, and for patients continuing on therapy, times were censored at date of last visit; analysis was performed using Kaplan-Meier estimates.

Results: We identified 23 patients treated on protocol-based therapy with single-agent TDM-1 and report on the 20 patients who had discontinued protocol, and hence, T-DM1 therapy. All patients received trastuzumab in the metastatic setting prior to initiation of T-DM1, with a median number of 6 (range 1-14) prior regimens. Most (75%) were taken off study secondary to progressive disease and the remainder discontinued therapy for toxicity. Of these 20 patients, 75% (15 of 20) received further therapy with or without anti-HER2 agents after concluding T-DM1; reasons for not receiving additional treatment after T-DM1 include death (3) and interruption of therapy due to physician or patient request (2). The majority (12 of 15; 80%) of patients treated beyond T-DM1 received a regimen containing either trastuzumab and/or lapatinib at some point during their course. Partial response to either first-or second-subsequent line(s) of therapy was seen in 5 of 15 (33%) treated patients, including 33% (4 of 12) who received a regimen containing trastuzumab and/or lapatinib (Figure 1). Three patients did not have radiographic assessments; however, all 3 demonstrated clinically stable disease (as determined by review of clinical data) to first treatment after T-DM1. Median duration of therapy to first-subsequent regimen after T-DM1 was 5.5 months. Of the 9 patients that received a second-subsequent regimen, the median duration of therapy to the second-subsequent treatment was 6.4 months.

Conclusions: In heavily pretreated HER2-positive MBC patients, prior exposure to T-DM1 does not exhaust the potential benefit of ongoing anti-HER2 therapy with trastuzumab and/or lapatinib-based regimens.

Maximum Decrease in Target Lesion Diameter

Coccidioidal spondylitis: MR findings in 15 patients

OBJECTIVE

MR imaging studies of 15 patients with documented vertebral column coccidioidomycosis infection were retrospectively reviewed to determine the MR imaging features of coccidioidal spondylitis.

CONCLUSION

On MR imaging, coccidioidal spondylitis may be unifocal or multifocal. Involvement of an intervertebral disk, vertebral body marrow, and adjacent epidural and soft tissue is generally seen.

Cervical and lumbar MRI in asymptomatic older male lifelong athletes: frequency of degenerative findings

OBJECTIVE

The athletic activity of the adult U.S. population has increased markedly in the last 20 years. To evaluate the possible long-term effects of such activity on the cervical and lumbar spine, we studied a group of asymptomatic currently very active lifelong male athletes over age 40 (41-69 years old, av. age 53).

MATERIALS AND METHODS

Nineteen active, lifelong male athletes were studied with MRI and the results compared with previous imaging studies of other populations. An athletic history and a spine history were also taken.

RESULTS

Evidence of asymptomatic degenerative spine disease was similar to that seen in published series of other populations. Degenerative changes including disk protrusion and herniation, spondylosis, and spinal stenosis were present and increased in incidence with increasing patient age. In this group, all MRI findings proved to be asymptomatic and did not limit athletic activity.

CONCLUSION

The incidence of lumbar degenerative changes in our study population of older male athletes was similar to those seen in other populations.

Fast SE MRI of the chest: parameter optimization and comparison with conventional SE imaging

OBJECTIVE

This study was performed to optimize scanning parameters for fast spin echo (FSE) T2-weighted scans of the chest and to compare FSE T2-weighted images with conventional spin echo (CSE) T2-weighted scans.

MATERIALS AND METHODS

Thirty-nine FSE T2-weighted scans of the chest were obtained in 12 subjects to determine the effect of cardiac gating (with gating n = 20; without gating n = 19) and combinations of number of excitations (NEX) (2,4,8,16) and echo train length (ETL) (2,4,8,16) on scan quality and visibility of thoracic structures. An additional 15 chest MR examinations consisting of FSE T2- and CSE T1-, proton-density- (PD), and T2-weighted scans were obtained in 15 patients with a variety of thoracic abnormalities. The FSE T2-weighted scans were compared with CSE T2-weighted scans, and the combination of CSE T1- and FSE T2-weighted scans was compared with the combination of CSE PD- and T2-weighted scans.

RESULTS

Little difference in image quality was found between cardiac-gated and nongated FSE scans. Increasing the ETL resulted in increased motion artifact. Forty lesions were detected with FSE and 42 lesions with CSE T2-weighted scans. Fifty-three lesions were detected with the combination of CSE T1- and FSE T2-weighted sequences, whereas 44 lesions were detected with the combination of CSE PD- and T2-weighted scans.

CONCLUSIONS

The combination of cardiac-gated CSE T1- and non-cardiac-gated FSE T2-weighted scans was 20% more sensitive and twice as fast as the combination of cardiac-gated CSE PD- and T2-weighted scans.

Mental status guide: FROMAJE for use with frail elders

1. There is no single pathognomonic sign, symptom, or clinical or laboratory test for making the diagnosis of dementia. A key element of the examination must be the inclusion of a mental status evaluation. 2. The FROMAJE--an acronym for Function, Reasoning, Orientation, Memory, Arithmetic, Judgment, and Emotion--Mental Status Guide (FMSG) has the advantage of a clear relationship between the acronym and the characteristics being measured. 3. The FMSG is meant to serve as a guide for the primary care clinician, who may have little experience in formal mental status testing. It is a convenient cognitive screening instrument to detect dementia in the elderly.

MR detection of white matter disease of the brain in patients with HIV infection: fast spin-echo vs conventional spin-echo pulse sequences

OBJECTIVE

Although fast spin-echo images and slower spin-echo images have similar contrast characteristics, the two techniques have not yet been shown to be equivalent in all aspects of brain imaging. To determine if the two sequences are equivalent, we compared detection of white matter lesions, image quality, and artifact degradation on fast spin-echo and spin-echo proton density-weighted and T2-weighted MR images of the brain in prospectively selected patients who were seropositive for HIV.

SUBJECTS AND METHODS

Fast spin-echo and spin-echo MR images of the brain were obtained in 153 consecutive subjects. The images were reviewed independently by three experienced neuroradiologists. The size, number, and location of white matter lesions were compared for the two techniques. Image quality, motion artifact, CSF flow artifact, and gray-white matter differentiation were graded on a five-point scale.

RESULTS

No statistical difference was found in gray-white matter differentiation. Overall image quality, CSF flow artifacts, and motion artifacts were slightly worse on the fast spin-echo images (p < .05). Although some variability existed in the detection of lesions less than 5 mm in diameter, the differences was small, and all larger lesions were detected by both techniques. Agreement between fast spin-echo and conventional spin-echo techniques was nearly exact with respect to characterizing findings in brain as either normal or abnormal.

CONCLUSIONS

Fast spin-echo and spin-echo MR of the brain produce images of similar quality and show white matter lesions equally well. These results support the replacement of slower, conventional spin-echo pulse sequences with faster fast spin-echo sequences.

Cystosarcoma phyllodes of the prostate: MRI findings

Cystosarcoma phyllodes of the prostate is a rare, relatively benign sarcoma of the prostate. We describe the magnetic resonance imaging findings in an unusual case of cystosarcoma phyllodes which resulted in extensive local recurrence and sarcomatous degeneration. Although uncommon, radiologists should be aware of the existence of cystosarcoma phyllodes of the prostate.

Extraspinal abnormalities detected on MR images of the spine

Surface-coil MR imaging of the spine is one of the most commonly performed MR imaging procedures. As the spine is the region of interest in these studies, extraspinal abnormalities may be overlooked. Such lesions can be difficult to perceive because they are out of the area of interest or distant from the surface coil. MR studies may be interpreted without other radiographic studies for comparison, as the other studies often have been performed elsewhere. Consequently, it is important for radiologists to be aware of the extraspinal anatomy and the appearances of extraspinal abnormalities. We describe the appearances of some common extraspinal diseases and normal variants detected with surface-coil MR imaging of the spine.

Diseases of the lumbar spine: findings on fat-suppression MR imaging

Fat-suppression MR techniques have been useful in imaging both the head and neck and the orbit. The lumbar spine is not as complex as the head and neck and does not contain as much fat as the orbit. Nevertheless, high signal from epidural and marrow fat in the lumbar spine can make it difficult to detect and define pathologic processes. In addition, the administration of gadopentetate dimeglumine can cause some infectious and neoplastic lesions of the spine to become isointense with fat on T1-weighted images. Compared with conventional MR imaging without fat suppression, contrast-enhanced fat-suppression MR imaging can better differentiate these enhancing lesions from surrounding fat. In this essay, we illustrate the findings of fat-suppression MR imaging in a variety of diseases of the lumbar spine.

Frontal sinus fractures: evaluation of CT scans in 132 patients

PURPOSE

To determine the frequency of detection of frontal sinus fractures on initial CT scans of patients with intracranial injuries, and to characterize associated injuries.

METHODS

The initial head CT scans in 132 patients with clinical or radiographic evidence of a frontal sinus fracture were retrospectively reviewed to further characterize the fracture. Additional radiographic studies and medical records were reviewed to determine associated injuries, therapy, clinical outcome, and complications.

RESULTS

In 90% (124) of the patients, the frontal sinus fractures were visualized on initial head CT scans that were obtained to evaluate suspected intracranial injury. Complex fractures involving both the anterior and posterior wall of the sinus accounted for 65% of cases (86 patients), whereas fractures of the anterior wall only or posterior wall only occurred in 24% (32) and 11% (14) of patients, respectively. Significant intracranial hemorrhage occurred in over 90% of patients with fractures involving the posterior wall.

CONCLUSIONS

In general, fractures that involved the posterior wall had more complications and a worse clinical outcome than fractures that only involved the anterior wall; nearly all frontal sinus fractures can be detected on head CT studies in patients with intracranial injuries.

Osseous metastasis in medulloblastoma: MRI findings in an unusual case

An 11-year-old boy with a history of medulloblastoma developed blastic osseous metastases. The metastases were detected by noting diffuse areas of low signal intensity within the calvarium on T1-weighted and T2-weighted magnetic resonance (MR) scans of the brain. The MR appearance of osseous metastases in medulloblastoma has not been reported previously. Extraneural metastases in medulloblastoma are relatively rare. The literature is briefly reviewed.

Mechanism of the positive inotropic effect of milrinone in cultured embryonic chick ventricular cells

Milrinone, a potent positive inotropic and vasodilating agent, has shown promise in the clinical treatment of congestive heart failure, but significant controversy about its mechanism of action exists. To approach these mechanistic problems in a non-innervated, non-diffusion-limited system, the effects of milrinone on cultured embryonic chick ventricular cells were examined. At 37 degrees C in physiologic buffer, milrinone produced a rapid, concentration-dependent increase in amplitude of contraction that was 45% of the maximum increment in contraction produced by elevated extracellular calcium; the EC50 was 8 microM. This peak response was quantitatively similar to the contractile response produced by isobutyl methylxanthine, a potent phosphodiesterase inhibitor. Milrinone inhibited 70% of total phosphodiesterase activity of cultured ventricular cells with an EC50 of 11 microM. Exposure to 1 X 10(-4) M milrinone resulted in rapid increase in cyclic AMP content to levels greater than 100% above control within 4 min. The same concentration also produced a 43% increase in the rate of transsarcolemmal 45Ca uptake. The stimulation of 45Ca uptake rate was similar to the response produced by 1 microM isoproterenol and could be completely abolished by 10 microM verapamil. Thus, in cultured embryonic chick myocardial cells, the positive inotropic effect of milrinone is largely, if not entirely, attributable to phosphodiesterase inhibition, leading to intracellular cyclic AMP accumulation and stimulation of transsarcolemmal calcium influx via the slow calcium channel.

Immunological assay of pancreatic ribonuclease in serum as an indicator of pancreatic cancer

Serum levels of RNase activity, presumed to originate in the pancreas, have been suggested to be of use in the diagnosis of pancreatic cancer. We have used a radioimmunological assay of human pancreatic-like RNase to quantitate this protein in serum from normal blood donors and patients with a variety of diseases. Serum pancreatic-like RNase rises gradually with age, and its level is usually higher in males than females. Although many patients with pancreatic cancer show elevated serum levels of immunologically cross-reactive enzyme, others are apparently normal. In several other types of cancer, a similar pattern of elevated RNase is apparent. However, in kidney or bladder carcinoma and in patients with severe kidney disease, RNase levels are almost always greater than normal. Regardless of the nature of the disease, an elevated level of pancreatic-like enzyme is usually accompanied by above-normal levels of serum urea nitrogen. Hence, elevated circulating levels of pancreatic-like RNase are best related to kidney function and do not serve as a specific marker for cancers of the pancreas or other organs.