Phenotypical differences of C9ORF72 gene-positive and negative amyotrophic lateral sclerosis: a comparative case series

BACKGROUND

Hexanucleotide repeat expansions of C9ORF72 account for a significant proportion of autosomal dominant neurodegenerative diseases in the amyotrophic lateral sclerosis (ALS)-frontotemporal dementia spectrum. In the absence of a family history, clinical identification of such patients remains difficult. We aimed to identify differences in demographics and clinical presentation between patients with C9ORF72 gene-positive ALS (C9pALS) versus C9ORF72 gene-negative ALS (C9nALS), to aid identification of these patients in the clinic and examine differences in outcomes including survival.

METHODS

We retrospectively reviewed the clinical presentations of 32 patients with C9pALS and compared their characteristics with a cohort of 46 patients with C9nALS from the same tertiary neurosciences centre.

RESULTS

Patients with C9pALS more commonly presented with mixed upper and lower motor signs (C9pALS 87.5%, C9nALS 65.2%; p=0.0352), but less frequently presented with purely upper motor neuron signs (C9pALS 3.1%, C9nALS 21.7%; p=0.0226). The C9pALS cohort had a higher frequency of cognitive impairment (C9pALS 31.3%, C9nALS 10.9%; p=0.0394) and bulbar disease (C9pALS 56.3%, C9nALS 28.3%; p=0.0186). There were no differences between cohorts in age at diagnosis, gender, limb weakness, respiratory symptoms, presentation with predominantly lower motor neuron signs or overall survival.

DISCUSSION

Analysis of this ALS clinic cohort at a UK tertiary neurosciences centre adds to the small but growing understanding of the unique clinical features of patients with C9pALS. In the age of precision medicine with expanding opportunities to manage genetic diseases with disease-modifying therapies, clinical identification of such patients is increasingly important as focused therapeutic strategies become available.

MRI characteristics of nodular fasciitis of the musculoskeletal system

OBJECTIVE

To evaluate MRI imaging appearances of nodular fasciitis in a pathologic-proven series of 29 patients.

MATERIALS AND METHODS

Review of the orthopedic oncology and pathology databases yielded 51 cases of histologically proven nodular fasciitis. MR imaging was available in 29 patients. Three musculoskeletal radiologists retrospectively reviewed all cases in consensus. Imaging features evaluated included location in the body, size, compartmental localization, relationship to fascia, signal characteristics, enhancement pattern, transcompartmental extension, and osseous and intra-articular involvement.

RESULTS

There were 15 male and 14 female patients. Mean age was 33 years (range, 16-59 years). Lesions ranged in size from 1.6 to 9 cm with 84 % of lesions measuring less than 4 cm. Twenty-three lesions were located in the upper arm or shoulder girdle. Nine lesions were subcutaneous in location, nine were intra-muscular, and 11 were inter-muscular. Lesions were consistently ovoid in shape with broad fascial contact. They exhibited internal homogenous low T1 and heterogeneous intermediate T2 signal with surrounding edema and slightly inhomogeneous enhancement. Twelve lesions exhibited central non-enhancing areas. Trans-compartmental spread was demonstrated in nine lesions. Osseous changes were seen in five cases and included extrinsic cortical saucerization, medullary edema, and transcortical osseous invasion. Two lesions demonstrated intra-articular extension.

CONCLUSIONS

MR imaging features of nodular fasciitis are generally non-specific and can be mistaken for a soft tissue sarcoma. This series, the largest MRI series of musculoskeletal cases in the literature, confirms the predilection of nodular fasciitis for the upper extremity in young adults but also demonstrates that aggressive imaging features such as transcompartmental spread, and osseous and intra-articular involvement may be seen in association with this benign soft tissue lesion.

Multimodal approach in the use of clinical scoring, morphological MRI and biochemical T2-mapping and diffusion-weighted imaging in their ability to assess differences between cartilage repair tissue after microfracture therapy and matrix-associated autologous chondrocyte transplantation: a pilot study

OBJECTIVE

The aim of the present pilot study is to show initial results of a multimodal approach using clinical scoring, morphological magnetic resonance imaging (MRI) and biochemical T2-relaxation and diffusion-weighted imaging (DWI) in their ability to assess differences between cartilage repair tissue after microfracture therapy (MFX) and matrix-associated autologous chondrocyte transplantation (MACT).

METHOD

Twenty patients were cross-sectionally evaluated at different post-operative intervals from 12 to 63 months after MFX and 12-59 months after MACT. The two groups were matched by age (MFX: 36.0+/-10.4 years; MACT: 35.1+/-7.7 years) and post-operative interval (MFX: 32.6+/-16.7 months; MACT: 31.7+/-18.3 months). After clinical evaluation using the Lysholm score, 3T-MRI was performed obtaining the MR observation of cartilage repair tissue (MOCART) score as well as T2-mapping and DWI for multi-parametric MRI. Quantitative T2-relaxation was achieved using a multi-echo spin-echo sequence; semi-quantitative diffusion-quotient (signal intensity without diffusion-weighting divided by signal intensity with diffusion weighting) was prepared by a partially balanced, steady-state gradient-echo pulse sequence.

RESULTS

No differences in Lysholm (P=0.420) or MOCART (P=0.209) score were observed between MFX and MACT. T2-mapping showed lower T2 values after MFX compared to MACT (P=0.039). DWI distinguished between healthy cartilage and cartilage repair tissue in both procedures (MFX: P=0.001; MACT: P=0.007). Correlations were found between the Lysholm and the MOCART score (Pearson: 0.484; P=0.031), between the Lysholm score and DWI (Pearson:-0.557; P=0.011) and a trend between the Lysholm score and T2 (Person: 0.304; P=0.193).

CONCLUSION

Using T2-mapping and DWI, additional information could be gained compared to clinical scoring or morphological MRI. In combination clinical, MR-morphological and MR-biochemical parameters can be seen as a promising multimodal tool in the follow-up of cartilage repair.

Quantitative MR imaging evaluation of the cartilage thickness and subchondral bone area in patients with ACL-reconstructions 7 years after surgery

OBJECTIVE

To evaluate the cartilage thickness (ThC) and subchondral bone area (tAB) of the operated and contra-lateral non-operated (healthy) knees in patients with anterior cruciate ligament (ACL)-reconstruction 7 years after surgery using a quantitative and regional cartilage MR imaging (qMRI) technique.

METHODS

Charts of 410 patients with ACL-reconstructions were retrospectively reviewed. Fifty-two patients (male/female, 28/24; mean age, 33.3 years) were included. Patients underwent KT-1000 testing and qMRI of both knees using coronal fat-saturated 3D spoiled gradient-recalled echo (SPGR) sequences (TR/TE, 44/4 ms) at 1.5 T. Quantitative analyses of ThC and tAB in the femoro-tibial cartilage plates were performed using a subregional approach. In addition, qualitative and quantitative assessment of femoral condyle shapes was performed. t tests with Bonferroni corrections were used for statistical analysis of side-to-side differences between the operated and non-operated knees.

RESULTS

KT-1000 testing was abnormal in 3/52 patients (6%). Lateral femoral tAB was significantly lower (-9.2%), and medial tibial tAB was significantly larger (+2%) in the operated vs non-operated knee (P<0.001). Regional and subregional ThC side-to-side differences were less than 0.1mm and, except for the external lateral femoral subregion, they were not statistically significant. Flattened and broader shapes of medial femoral condyles (P<0.001) were found in operated knees. No significant association of presence of cartilage or meniscus lesions at surgery with ThC 7 years post-operatively was found (P=0.06-0.98).

CONCLUSION

There is evidence for changes in the tAB and femoral shape 7 years post-ACL-reconstruction, but no side-to-side differences in subregional ThC were found between the operated and contra-lateral non-operated knees.

Transarticular invasion of bone tumours across the sacroiliac joint

PURPOSE

The purpose of this study was to evaluate the pattern of tumour spread across the SI articulation, correlating with cadaveric anatomic observations, in order to better understand the local spread of tumour and to assist in the assessment of local staging.

MATERIAL AND METHODS

Twenty-four consecutive patients (14 male, 10 female; age range 22-89 years, mean 52 years) with primary bone tumours of the iliac bone or sacrum abutting the SI joint, in whom surgical resection of the SI joint was performed, were studied following institutional ethics approval. In all patients, preoperative magnetic resonance (MR) imaging studies of the pelvis and SI joint were reviewed for imaging evidence of transarticular extension across the SI joint. Gross pathologic and histologic assessment of possible transarticular SI joint tumour extension was performed in all patients. Nine cadaveric pelvic specimens without pelvic neoplastic disease (4 male, 5 female; age range 20-84 years, mean 59 years, median 58 years) were anatomically dissected and the articular anatomy of the SI joint examined macroscopically.

RESULTS

Twelve of the twenty-four patients demonstrated imaging and histological evidence of transarticular SI joint invasion. Eight tumours infiltrated only the interosseous ligamentous aspect of the SI joint. In the remaining four cases, extensive tumour infiltrated both the cartilaginous and ligamentous aspects of the joint. No case showed tumour involvement isolated to the cartilaginous aspect of the joint. Among the cadaveric specimens studied, degenerative changes were found involving the majority of cases (6/9), with cartilage thinning and fibrillation and antero-superior marginal osteophytes seen involving the cartilaginous portion of the SI joint articulation. Four of the nine specimens demonstrated central ossification bridging the iliac and sacral aspects of the ligamentous (interosseous) SI joint.

CONCLUSION

Tumour invasion across the SI articulation favours its interosseous ligamentous portion. Factors influencing transarticular tumour extension and its preferential course across the interosseous component of the articulation have been discussed. It is particularly important to assess the interosseous ligamentous portion of the SI articulation when locally staging primary pelvic bone tumours subjacent to the SI articulation, as this will have a significant impact on planning surgical management.

Effect of zoledronate on bone quality in the treatment of aseptic loosening of hip arthroplasty in the dog

Periprosthetic bone loss, which is a direct cause of aseptic loosening in total hip arthroplasty (THA), can be suppressed by bisphosphonates. It is unknown how the quality of this bone is affected in the presence of both wear debris (from implant) and bisphosphonates. The objective of this study was to evaluate the effect of zoledronate (ZLN) on bone quality in the presence of wear debris [polyethylene (PE) particles] in a canine model of uncemented THA. Thirty dogs underwent THA, and aseptic loosening was induced via implantation of PE particles packed into the femoral component. For 26 weeks until sacrifice, two groups (each n = 10) received weekly injections of ZLN (low dose 2 mug/kg, high dose 10 mug/kg) and the third group (control) received saline. Histological and radiographic examinations were performed to evaluate the degree of implant reaction. Histomorphometry (static/dynamic) was performed to evaluate bone turnover. Back-scattered electron imaging was used to quantify the newly formed bone and to evaluate the mineralization distribution. Density fractionation and X-ray diffraction were used to evaluate mineral properties, while four-point bending was used to determine mechanical properties. A dose-dependent presence of newly formed subperiosteal bone was found, which appeared to be less mineralized than the adjacent cortical bone. The high-dose ZLN group showed decreased cortical porosity and turnover and increased mineralization profile, failure strength, and modulus. We conclude that ZLN affects some of the material properties of cortical bone and allows the newly formed subperiosteal bone to remain and therefore affect the overall quality of the bone.

Imaging of patellofemoral disorders

Anterior knee pain is a common symptom, which may have a large variety of causes including patellofemoral pathologies. Patellofemoral maltracking refers to dynamic abnormality of patellofemoral alignment and has been measured using plain film, computed tomography (CT) and magnetic resonance imaging (MRI) using static and kinematic techniques. Patellar dislocation is usually transient, but specific conventional radiographic and MRI features may provide evidence of prior acute or chronic dislocation. In addition, chondromalacia patellae, osteochondritis dissecans, patellofemoral osteoarthritis, excessive lateral pressure syndrome, and bipartite patella have all been implicated in causing patellofemoral pain. The imaging and clinical features of these processes are reviewed, highlighting the specific diagnostic features of each condition.

Anteromedial impingement of the ankle: using MR arthrography to assess the anteromedial recess

OBJECTIVE

Our objective was to describe the appearance of the anteromedial tibiotalar joint on MR arthrography in patients with clinically and arthroscopically confirmed anteromedial impingement.

CONCLUSION

Anteromedial impingement of the ankle is now being recognized in the orthopedic literature as a distinct entity. MR arthrographic findings of anteromedial impingement include capsular and synovial soft-tissue thickening anterior to the tibiotalar ligaments and any associated osseous abnormality. Although anteromedial impingement is uncommon compared with other impingement syndromes of the ankle, the radiologist should be aware of the diagnosis and possible findings on cross-sectional imaging.

Periosteal chondroid tumors: radiologic evaluation with pathologic correlation

OBJECTIVE

The purpose of this study was to determine whether the imaging features of periosteal chondroid tumors correlate with histopathology.

MATERIALS AND METHODS

Twenty-two patients (nine women and 13 men; mean age, 33 years) with pathologically proven periosteal chondroid lesions were retrospectively reviewed. The imaging modalities included conventional radiography (n = 17), CT (n = 10), and MR imaging (n = 14). The images were reviewed by two osteoradiologists, with agreement by consensus. Evaluation criteria included lesion location, mineralization, and size; periosteal reaction; and cortical response. Intramedullary extension, adjacent intramedullary edema, soft-tissue edema, and intrinsic characteristics were also evaluated on MR imaging. After the evaluation, a radiologic diagnosis of chondroma or chondrosarcoma was obtained. An experienced osteopathologist who was unaware of the patient's medical history and radiologic findings reviewed all histopathology. Agreement between the radiologic and the histopathologic diagnosis was tested using the kappa analysis. Imaging features were correlated with the pathologic findings, and a statistical analysis was performed.

RESULTS

Using strict pathologic criteria, we diagnosed 11 chondromas and 11 chondrosarcomas (nine, grade I; two, grade II). Moderate agreement was reached between the radiologic and the pathologic diagnosis (kappa = 0.55). The size of periosteal chondrosarcomas (range, 3-14 cm; median, 4 cm) was considerably larger than the size of the chondromas (range, 1-6.5 cm; median, 2.5 cm; p < 0.05). Other imaging features did not significantly correlate with benign versus malignant disease at pathology (all p > 0.05).

CONCLUSION

A variable overlap existed in the imaging appearances of benign and malignant periosteal chondroid lesions, with size being the most reliable indicator in distinguishing the two lesions. This and the fact that histologic differentiation of the entities can be difficult, suggests that surgical wide excision may be the most appropriate procedure in treating patients with lesions greater than 3 cm.

Anterolateral ankle impingement: mr arthrographic assessment of the anterolateral recess

PURPOSE

To determine the accuracy of magnetic resonance (MR) arthrography in assessing the anterolateral recess of the ankle.

MATERIALS AND METHODS

Thirty-two patients with chronic ankle pain prospectively underwent gadolinium-enhanced MR arthrography of the tibiotalar joint. All underwent clinical examination and were included if anterolateral impingement (n = 13) or a control condition (n = 19; suspected osteochondral defect, intraarticular bodies, instability, osteoarthritis) was diagnosed. MR imaging included transverse and coronal T1-weighted and sagittal T2-weighted imaging sequences. Images were prospectively analyzed by two readers blinded to the clinical diagnosis. The anterolateral gutter contour was assessed. MR arthrographic findings were correlated with subsequent arthroscopic appearances.

RESULTS

MR arthrographic assessment of the anterolateral soft tissues had an accuracy of 97%, sensitivity of 96%, specificity of 100%, negative predictive value of 89%, and positive predictive value of 100%. Accuracy was 100% with clinical anterolateral impingement, with an arthroscopically confirmed abnormality in 12 cases and a normal appearance in one. Anterolateral soft-tissue thickening was identified at MR arthrography in 11 control cases, with arthroscopic confirmation in all. The remaining cases had normal appearances, with an arthroscopic soft-tissue abnormality in one case and a normal appearance in seven.

CONCLUSION

MR arthrography of the tibiotalar joint is accurate in assessing the anterolateral recess of the ankle.

Osteoid-producing tumors of bone

Osteoid-producing skeletal tumors are commonly encountered lesions by radiologists. Lesions include both benign tumors--osteoma, enostosis, osteoid osteoma, and osteoblastoma--as well as the malignant neoplasm, osteosarcoma. Radiologic features of these lesions are emphasized in this article and are frequently diagnostic. In addition, clinical characteristics, treatment, and prognosis are reviewed.

Unsuspected metastases presenting as solitary soft tissue lesions: a fourteen-year review

OBJECTIVE

To describe a series of patients with no known primary malignancy who presented with a solitary unsuspected soft tissue metastasis masquerading as a soft tissue sarcoma, and secondarily to describe the imaging appearance of these lesions.

DESIGN

Records of two academic hospitals with active orthopedic oncology services were reviewed for patients meeting the above criteria. Clinical charts were examined, and the imaging appearance of the soft tissue lesions retrospectively reviewed.

PATIENTS

Of 1421 patients examined for soft tissue lesions, 11 were found who met the above criteria.

RESULTS

Of the 11 patients whose initial presentation was a solitary soft tissue metastasis, eight were found to have a primary lung cancer, two were diagnosed with adenocarcinoma of unknown primary, and adenocarcinoma of the colon was discovered in the remaining patient.

CONCLUSIONS

The clinical presentation of a solitary soft tissue metastasis without a known primary malignancy is a rare occurrence, with an incidence of approximately 0.8%. Lung cancer is the primary neoplasm in a high percentage of these cases.

Complications of total hip arthroplasty: MR imaging-initial experience

PURPOSE

To investigate the use of standard magnetic resonance (MR) imaging sequences with simple parameter modifications for the detection and characterization of total hip arthroplasty (THA) complications.

MATERIALS AND METHODS

An initial phantom study was performed with cobalt-chrome and titanium prostheses to establish the imaging parameters for a subsequent clinical study. In the clinical study, coronal and transverse MR imaging of 14 THA prostheses was performed before and after intravenous contrast material administration in 12 patients who were being considered for revision arthroplasty. The images were reviewed for evidence of juxtaarticular or periprosthetic abnormalities, patterns of contrast enhancement, and quality of periprosthetic tissue depiction.

RESULTS

Phantom study results showed improved periprosthetic tissue depiction with use of thin sections, increased frequency-encoding gradient strength, and fast spin-echo sequences. The clinical study results demonstrated periprosthetic abnormalities in 11 cases: mechanical loosening in two cases (including one case with an associated periprosthetic fracture); granulomatosis, eight; and infection, one. In 100% of cases, tissue depiction around the femoral component was judged to be of "diagnostic quality." Tissue depiction around the acetabular component was of diagnostic quality in five (36%) cases. In all seven surgically confirmed cases, a correct diagnosis was made preoperatively with MR imaging.

CONCLUSION

By using simple modifications to standard MR imaging sequences, diagnostic-quality MR imaging of THA complications can be performed, particularly around the femoral prosthetic stem.

Ultrasonographic prediction of fetal macrosomia. Association with cesarean delivery

OBJECTIVE

To investigate whether the incorrect ultrasonographic prediction of macrosomia affects the cesarean delivery rate among nonmacrosomic neonates.

STUDY DESIGN

For this retrospective, cohort study, comprehensive ultrasonographic records were reviewed at two centers. Patients with singleton, nonanomalous gestations whose ultrasonography predicted an estimated fetal weight > or = 4,000 g composed one cohort (n = 135), while the other cohort (n = 129) consisted of patients whose ultrasonography predicted an estimated fetal weight between 3,000 and 3,999 g. We compared the cesarean delivery rate in neonates falsely diagnosed with macrosomia (false positives) with the rate in those correctly diagnosed as nonmacrosomic (true negatives).

RESULTS

The rate of cesarean delivery was significantly higher among those falsely diagnosed by ultrasonography with a macrosomic fetus as compared to those with a fetus truly diagnosed as nonmacrosomic (42.3% vs. 24.3%, relative risk = 1.74, 95% confidence interval 1.09-2.78). Subgroup analyses excluding diabetic mothers and multiparous women and comparing false positives with true negatives with neonatal birth weights between 3,500 and 4,000 g (birth weights similar to false positives) demonstrated significantly increased cesarean delivery rates among false positives.

CONCLUSION

Even in nonmacrosomic neonates, the antenatal ultrasonographic diagnosis of suspected macrosomia is associated with a significant increase in cesarean delivery rates.

Periprosthetic bone remodelling around a prosthesis for distal femoral tumours. Measurement by dual-energy X-ray absorptiometry (DEXA)

We used dual-energy x-ray absorptiometry (DEXA) to evaluate the extent of periprosthetic bone remodelling around a prosthesis for distal femoral reconstruction, the Kotz modular femoral tibial replacement (KMFTR; Howmedica, Rutherford, New Jersey). A total of 23 patients was entered into the study which had four parts: 1) 17 patients were scanned three times on both the implant and contralateral legs to determine whether the precision of DEXA measurements was adequate to estimate bone loss surrounding the anchorage piece of the KMFTR; 2) in 23 patients the bone mineral density (BMD) in different regions of interest surrounding the diaphyseal anchorage was compared with that of the contralateral femur at the same location to test whether there was consistent evidence of loss of BMD adjacent to the prosthetic stem; 3) in 12 patients sequential studies were performed about one year apart to compare bone loss; and 4) bone loss was compared in ten patients with implants fixed by three screws and in 13 without screws. The mean coefficients of variation (SD/mean) for the 17 sets of repeated scans ranged from 2.9% to 7.8% at different regions of interest in the KMFTR leg and from 1.4% to 2.5% in the contralateral leg. BMD was decreased in the KMFTR leg relative to the contralateral limb and the percentage of BMD loss in general increased as the region of interest moved distally in the femur. Studies done after one year showed no consistent pattern of progressive bone loss between the two measurements. The ten patients with implants fixed by screws were found to have a mean loss of BMD of 42% in the most distal part of the femur, while the 13 without screw fixation had a mean loss of 11%. DEXA was shown to have adequate precision to evaluate loss of BMD around the KMFTR. This was evident relative to the contralateral leg in all patients and generally increased in the most distal part of the femur. In general, it stabilised between two measurements taken one year apart and was greater surrounding implants fixed by cross-locking screws.

Comparison between a 2- and 3-grade system in predicting metastatic-free survival in extremity soft-tissue sarcoma

BACKGROUND AND OBJECTIVES

The purpose of this study was to determine whether a histologic grading system consisting of 2 or 3 categories had better discrimination for predicting metastasis-free survival in extremity soft-tissue sarcoma.

METHODS

One hundred thirty patients with nonmetastatic soft-tissue sarcoma were identified and the histologic grade (3-grade system) for each tumor was determined. For the 2-grade system, grade was determined by collapsing 3 grades into 2. The Kaplan-Meier method was used to estimate disease free survival.

RESULTS

By use of a 3-grade system, grade 2 tumors showed a 5.2-fold and grade 3 tumors a 9-fold increased risk of systemic relapse when compared with grade 1 tumors. When grade 2 and 3 tumors were combined, they had a 2.6-fold increased risk of systemic relapse compared with grade 1 tumors. When grade 1 and 2 tumors were combined, grade 3 tumors had an 8.4-fold risk of relapse. After data were controlled for size and depth of tumor, each increase in grade in the 3-grade system showed a successive 2.3-fold increase in risk of systemic relapse.

CONCLUSIONS

A 3-grade system may be more appropriate for predicting systemic relapse than 2 grades. A prospective study is required to confirm this.

Treatment of giant-cell tumors of long bones with curettage and bone-grafting

BACKGROUND

The use of curettage, phenol, and cement is accepted by most experts as the best treatment for giant-cell tumor of bone. The present study was performed to evaluate whether equivalent results could be obtained with curettage with use of a high-speed burr and reconstruction of the resulting defect with autogenous bone graft with or without allograft bone.

METHODS

The prospectively collected records of patients who had a giant-cell tumor of a long bone were reviewed to determine the rate of local recurrence after treatment with curettage with use of a high-speed burr and reconstruction with autogenous bone graft with or without allograft bone. All of the patients were followed clinically and radiographically, and a biopsy was performed if there were any suspicious changes.

RESULTS

Fifty-nine patients met the criteria for inclusion in the study. According to the grading system of Campanacci et al., two patients (3 percent) had a grade-I tumor, twenty-nine (49 percent) had a grade-II tumor, and twenty-eight (47 percent) had a grade-III tumor. Seventeen patients (29 percent) had a pathological fracture at the time of presentation. The mean duration of follow-up was eighty months (range, twenty-eight to 132 months). Seven patients (12 percent) had a local recurrence. Six of these seven were disease-free at the latest follow-up examination after at least one additional treatment with curettage or soft-tissue resection (one patient). One patient had resection and reconstruction with a prosthesis after a massive local recurrence and pulmonary metastases.

CONCLUSIONS

Despite the high rates of recurrence reported in the literature after treatment of giant-cell tumor with curettage and bone-grafting, the results of the present study suggest that the risk of local recurrence after curettage with a high-speed burr and reconstruction with autogenous graft with or without allograft bone is similar to that observed after use of cement and other adjuvant treatment. It is likely that the adequacy of the removal of the tumor rather than the use of adjuvant modalities is what determines the risk of recurrence.

Primary leiomyosarcoma of bone

OBJECTIVE

This study describes radiographic and MR imaging features of primary leiomyosarcoma of bone.

SUBJECTS AND METHODS

Twelve patients (five men and seven women, 39-79 years old) who were treated at two oncology centers for primary leiomyosarcoma of bone involving the femurs, tibia, ilium, and inferior pubic ramus were studied. None of the patients had preexisting disease or disease elsewhere at the time of diagnosis. Pathologic diagnosis was obtained in all patients.

RESULTS

Radiographs of all patients showed a matrix that was exclusively osteolytic. In long bones (seven patients), the tumor had an average length of 11 cm (range, 7-17 cm) and revealed an elongated configuration. In the pelvis (five patients), the average length of the tumor was 10 cm (range, 4-15 cm). MR imaging confirmed an intramedullary lesion in all patients, with extension into the soft tissues in eight patients and no identifiable soft-tissue mass in the remaining four patients. Four of the five pelvic tumors had a prominent soft-tissue mass, whereas only four of the seven long bone lesions revealed a soft-tissue mass that was, in all instances, small. The tumor was hypointense on T1-weighted images and showed heterogeneous signal intensity on T2-weighted conventional and fast spin-echo sequences. We saw low signal intensity (short T2) in eight patients and homogeneous hyperintense signal intensity in one patient. In the remaining three patients, T2-weighted spin-echo sequences obtained with fat saturation showed high signal intensity (long T2) in the tumors.

CONCLUSION

Primary leiomyosarcoma of bone is a rare tumor that on radiography reveals no matrix and on MR imaging reveals areas of T2 shortening in relation to fat on conventional and fast spin-echo sequences.

Relaxation of imprinting in Prader-Willi syndrome

We describe two Prader-Willi syndrome (PWS) patients who exhibit maternal uniparental disomy (UPD) of chromosome 15 and unusual patterns of gene expression and DNA replication. Both were diagnosed during infancy as having PWS; however, their growth and development were atypical compared with others with this condition. Weight was below normal in the first patient, and height and development were within normal limits in the second individual. Hyperphagia and polyphagia were not evident in either patient. Genotypes at multiple genomic loci, allele-specific methylation, gene expression, and DNA replication were analyzed at D15S9 [ZNF127], D15S63 [PW71], SNRPN, PAR5, IPW, and D15S10 in these patients. The maternal imprint (based on the absence of gene expression, synchronous replication, and methylation of both alleles) was retained at SNRPN in these patients, as is the case in others with UPD. By contrast, cells from the first individual expressed PAR5 and ZNF127, whereas the second expressed a single IPW allele. Asynchronous DNA replication was observed in both patients at all loci, except SNRPN. These findings show that a subset of imprinted genes can be transcribed in some PWS patients with maternal UPD and that asynchronous DNA replication is coordinated with this pattern of gene expression. Relaxed imprinting in these patients is consistent with their milder phenotype.

Interstitial duplications of chromosome region 15q11q13: clinical and molecular characterization

Duplications of chromosome region 15q11q13 often occur as a supernumerary chromosome 15. Less frequently they occur as interstitial duplications [dup(15)]. We describe the clinical and molecular characteristics of three patients with de novo dup(15). The patients, two males and one female (ages 3-21 years), had nonspecific findings that included autistic behavior, hypotonia, and variable degrees of mental retardation. The extent, orientation, and parental origin of the duplications were assessed by fluorescent in situ hybridization, microsatellite analyses, and methylation status at D15S63. Two patients had large direct duplications of 15q11q13 [dir dup(15)(q11q13)] that extended through the entire Angelman syndrome/Prader-Willi syndrome (AS/PWS) chromosomal region. Their proximal and distal breaks, at D15S541 or D15S9 and between D15S12 and D15S24, respectively, were comparable to those found in the common AS/PWS deletions. This suggests that duplications and deletions may be the reciprocal product of an unequal recombination event. These two duplications were maternally derived, but the origin of the chromatids involved in the unequal crossing over in meiosis differs. In one patient, the duplication originated from two different maternal chromosomes, while in the other patient it arose from the same maternal chromosome. The third patient had a much smaller duplication that involved only D15S11 and parental origin could not be determined. There was no obvious correlation between phenotype and extent of the duplication in these patients.

Ephedrine pharmacokinetics after the ingestion of nutritional supplements containing Ephedra sinica (ma huang)

Nutritional supplements containing Ephedra sinica (ma huang), a botanical source of ephedrine alkaloids, have been linked to several episodes of ephedrine toxicity and at least 17 deaths, yet these products remain unregulated. Ten subjects were enrolled in a randomized, crossover study aimed at characterizing the pharmacokinetics of ephedrine after the ingestion of three commercially available ma huang products compared with a 25-mg ephedrine capsule. Pharmacokinetic parameters for botanical ephedrine were similar to those for synthetic ephedrine hydrochloride. Gender-based comparisons of Vss/F and CL/F revealed higher values for women than for men (Vss/F, 3.49 +/- 1.04 vs 2.98 +/- 0.73 l/kg; CL/F, 0.48 +/- 0.11 vs 0.37 +/- 0.11 l/hour x kg). The current study suggests that the increased incidence of ma huang toxicity does not stem from differences in the absorption of botanical ephedrine compared with synthetic ephedrine; rather, it results from accidental overdose often prompted by exaggerated off-label claims and a belief that "natural" medicinal agents are inherently safe.

MR imaging of symptomatic osteochondromas with pathological correlation

OBJECTIVE

To demonstrate the value of MR imaging in the diagnosis and differentiation of the various symptomatic complications of osteochondromas, providing pathological correlation with emphasis on the usefulness of MR imaging as a single imaging modality in these patients.

DESIGN

We retrospectively reviewed all MR examinations of clinically symptomatic osteochondromas (30 patients) performed at our institution between March 1990 and October 1997.

PATIENTS

Thirty patients had clinically symptomatic osteochondromas during the study period. Twenty patients were male and 10 were female. There were five cases of multiple osteochondromatosis. Pathological correlation was available in 24 patients.

RESULTS AND CONCLUSION

Symptomatic complications included fracture (7%), osseous deformity limiting range of motion (23%), vascular injury (7%), neurological compromise (10%), bursa formation (27%) and malignant transformation (27%). MR imaging was able to diagnose or suggest the etiology for the clinical symptomatology in all cases, demonstrating that it is an ideal imaging modality in the diagnostic evaluation of symptomatic complications of osteochondromas and often avoids the need for further imaging.

MR imaging of primary lymphoma of bone: variability of T2-weighted signal intensity

OBJECTIVE

The purpose of this study was to investigate the MR imaging characteristics of primary lymphoma of bone.

MATERIALS AND METHODS

Records of 27 patients with histologic and clinical evidence of primary lymphoma of bone were retrospectively reviewed. Nineteen of these patients underwent MR imaging before surgical biopsy and initiation of therapy. Fifteen of the 19 patients underwent conventional spin-echo T1- and T2-weighted imaging, and the other four patients underwent T1-weighted and fast spin-echo T2-weighted imaging with fat saturation. MR images were separately and independently reviewed by two observers for signal intensity characteristics and homogeneity on T1- and T2-weighted sequences. Signal intensity characteristics were correlated with semiquantitative histopathologic assessments of tumor fibrosis, maturity of fibrosis, and vascularity.

RESULTS

T1-weighted signal intensity ranged from isointense to hypointense relative to muscle for all lesions. Twelve of 19 cases showed heterogeneity of signal intensity on T2-weighted images. Predominant tumor T2-weighted signal intensities relative to fat for the 19 patients were assessed as hypointense (observer 1, n = 3; observer 2, n = 1), isointense (observer 1, n = 10; observer 2, n = 11), and hyperintense (observer 1, n = 6; observer 2, n = 7). No correlation among intralesional fibrosis, maturity of fibrosis, or intralesional vascularity and T2-weighted signal intensity characteristics was found.

CONCLUSION

T2-weighted MR imaging characteristics of primary lymphoma of bone vary and do not seem to be a simple reflection of histologic findings of intralesional vascularity or fibrosis.

Exclusion of uniparental inheritance of chromosome 15 in a fetus with a familial dicentric (Y;15) translocation

We present a prenatal case with a 45,X,dic(Y;15) (q11.23;p11.1) karyotype and describe the inheritance pattern of the chromosome 15s. Chromosome 15 has an imprinted region and inheritance of both chromosome 15 from one parent results in either Angelman syndrome (AS) (paternal inheritance) or Prader Willi syndrome (PWS) (maternal inheritance). Parental chromosome studies revealed that the father carried the same dicentric (Y;15) translocation. Since familial chromosome rearrangements can result in aberrant chromosomal segregation during meiosis, we wanted to exclude paternal uniparental inheritance of chromosome 15. By using DNA microsatellite markers at several 15q11q13 loci, we determined that the fetus had inherited his normal non-translocated chromosome 15 from his mother.

Arthrographic effect induced by therapeutic ultrasound in magnetic resonance imaging of the wrist: a preliminary investigation

OBJECTIVE

To evaluate the potential arthrographic effect of therapeutic ultrasound applied before magnetic resonance imaging (MRI) of the wrist.

SUBJECTS AND METHODS

MRI of the wrist was performed in 6 asymptomatic volunteers before and after ultrasound therapy of the carpus. For each patient, ultrasound therapy was performed by a trained physiotherapist for 10 minutes, with doses titrated to the maximum tolerated without pain. The amount of fluid within the wrist joints before and after therapy was assessed subjectively by 2 reviewers, as well as objectively by digital analysis.

RESULTS

Subjective appraisal of the images indicated that after ultrasound therapy there was an increase in joint fluid within the distal radioulnar joint in 4 volunteers, the midcarpal joint in 4 and the radiocarpal joint in 2. Computerized digital analysis of joint fluid confirmed an average volumetric increase in wrist joint fluid of 52.8% in 3 of the volunteers. The discomfort of the therapy was graded as 1/10 by 5 of the subjects and 4/10 by a single subject.

CONCLUSIONS

Therapeutic ultrasound may be a useful adjuvant tool in the noninvasive induction of joint fluid before MRI of the wrist.

Chondroblastoma with multiple distant soft tissue metastases

A case of metachronous distant soft tissue metastases from a primary rib chondroblastoma, occurring in a 60-year-old man 17 years following resection of the initial lesion, is described. Metastatic chondroblastomas are very rare and almost always involve the lungs. Discussed herein are the clinical, radiologic, and pathologic findings of this unusual case with comparison of our findings to other reports of metastasizing chondroblastomas.

Combination of low-dose niacin and pravastatin improves the lipid profile in diabetic patients without compromising glycemic control

OBJECTIVE

To determine the efficacy and tolerability of the addition of low-dose niacin (1.5 g/d) in a diabetic hypercholesterolemic population who were unable to attain desired lipid control with low-dose (20 mg) pravastatin monotherapy.

RESEARCH DESIGN AND METHODS

This was a prospective, open-label study conducted over a 14-week period. Twenty-three diabetic patients with low-density lipoprotein (LDL) cholesterol concentrations of at least 150 mg/dL after dietary therapy were recruited from the outpatient diabetes clinic of a university teaching hospital. After 4 weeks of dietary stabilization and baseline determination of the lipid profile and glycemic control, patients received pravastatin 20 mg once daily for 4 weeks. Laboratory parameters were reassessed and niacin was added to the regimen in qualifying patients. Over 2 weeks, patients' regimens were titrated to a maximal dosage of 500 mg tid. Patients continued to receive the combination regimen for 4 weeks and were reassessed.

MEASUREMENTS AND MAIN RESULTS

Sixteen patients (14 non-insulin-dependent diabetes mellitus, 2 insulin-dependent diabetes mellitus) completed the study. Mean fasting blood sugar and fructosamine concentrations were unchanged throughout the study. Five patients required minor alterations (3 increased, 2 decreased) in their hypoglycemic regimens during the study. The addition of low-dose niacin to pravastatin therapy resulted in a significant lowering of LDL cholesterol compared with pravastatin monotherapy.

CONCLUSIONS

Low-dose niacin is a promising addition to hydroxymethylglutaryl-coenzyme A reductase inhibitor therapy in the treatment of hypercholesterolemia in patients with diabetes mellitus.

The effect of training and experience on the magnetic resonance imaging interpretation of meniscal tears

To evaluate the effects of experience and training in the magnetic resonance imaging (MRI) diagnosis of meniscal tears 30 consecutive patients (60 menisci) in whom MRI of the knee with arthroscopic confirmation of meniscal status were studied. MRIs were interpreted by 10 reviewers of varying levels of training and experience ranging from first-year radiology residents to attending musculoskeletal radiologists. Sensitivity and specificity, and intraobserver variability of MRI interpretation of meniscal tears were calculated for each reviewer and compared to those of readers of the same and varying levels of MRI training and experience. Accuracy (range, 78% to 88%), sensitivity (range, 79% to 88%), and specificity (range, 72% to 94%) results were high, and intraobserver agreement was moderate to high (range, 0.49 to 0.77), in the diagnosis of meniscal tears for all reviewers with 4 or more years of radiology residency training and 3 months of formal MRI experience. In contrast, the accuracy (range, 63% to 82%), sensitivity (range, 58% to 79%), and specificity (range, 58% to 72%) results of reviewers with less experience and training were lower, with higher intraobserver variability. Our results suggest that experience and training play an important role in the accurate and reliable MRI diagnosis of meniscal tears.

Pharmacokinetics and cardiovascular effects of ma-huang (Ephedra sinica) in normotensive adults

The purpose of this study was to evaluate heart rate and blood pressure responses to a commercially available source of ma-haung, a natural source of the sympathomimetic substance, ephedrine, and to evaluate the pharmacokinetic properties of the product in normotensive, healthy adults. On day 1, twelve study participants were monitored with an ambulatory blood pressure device between hours 7 and 20. On day 2, they ingested four capsules of powdered ma-huang at hours 8 and 17 while again wearing the monitor between hours 7 and 20. Serial plasma samples were obtained and concentrations of ephedrine were analyzed by high-performance liquid chromatography. Pharmacokinetic parameters of ephedrine were determined from plasma concentration-time profiles. The ephedrine alkaloid content of each capsule was also determined by high-performance liquid chromatography. Six participants experienced a statistically significant increase in heart rate, but the effects on blood pressure were variable. The half-life, volume of distribution, clearance, and maximum concentration in plasma of ephedrine in the ma-huang product were similar to values previously reported for a 20 mg, immediate-release ephedrine tablet. Values for the absorption rate were considerably lower and time to reach maximum concentration was longer for the capsules, compared with the standard tablet. Variability in alkaloid content of ephedrine was low and yielded a mean dose of ephedrine at 19.4 mg; pseudoephedrine at 4.9 mg; and methylephedrine at 1.2 mg for a four-capsule dose. In summary, ma-haung had variable effects on blood pressure and increased heart rate in healthy, normotensive adults. Pharmacokinetic parameters for ephedrine were in agreement with those previously reported; however, the absorption rate was much slower after ingestion of ma-huang.

Shoulder impingement syndrome: influence of shoulder position on rotator cuff impingement--an anatomic study

OBJECTIVE

The purpose of the study was to investigate the relationship of the distal supraspinatus tendon to the coracoacromial arch on radiographs and MR imaging at various shoulder positions.

MATERIALS AND METHODS

Radiopaque and gadolinium-impregnated markers were sutured to the distal aspect of the supraspinatus tendon and along the coracoacromial ligament in three cadavers. While varying positions of the shoulder, we obtained gross anatomic visualization, radiographs, and MR images.

RESULTS

Impingement of the distal aspect of the supraspinatus tendon between the acromion and the greater tuberosity of the humerus was well visualized during forward flexion and abduction of more than 30 degrees. Shoulder impingement was best seen at 60 degrees forward flexion, 60 degrees abduction, and internal rotation.

CONCLUSION

MR imaging of different shoulder positions may help reveal the pathogenesis of shoulder impingement syndrome.

Primary lymphoma of the calcaneus

Primary non-Hodgkin's lymphoma (NHL) of bone is a rare condition. Presented herein is a case of primary NHL of the calcaneus illustrating many of the classic features of the disease. Emphasized in this report are the nonspecific clinical and conventional radiographic features of primary NHL of bone, which may mimic inflammatory, neuropathic, infectious, or other neoplastic conditions of the extremities. The importance of early cross-sectional radiologic studies, such as magnetic resonance imaging, lies in the early characterization of the mass-like features and local extent of such lesions, helping to raise the suspicion of neoplastic disease.

Magnetic resonance imaging of the musculoskeletal system. Part 5. The wrist

Musculoskeletal radiology has been transformed with the advent of magnetic resonance imaging. Magnetic resonance imaging provides visualization of the complex anatomy of the wrist and delineation of numerous pathologic processes, which are difficult to visualize with conventional imaging modalities. With the use of sophisticated pulse sequences and a dedicated extremity coil, magnetic resonance imaging allows evaluation of osseous and ligamentous injuries, arthritides, tumors, and tumor-like conditions. Magnetic resonance imaging techniques will be emphasized and anatomy and various pathologic conditions pertaining to the wrist will be reviewed.

The role of T2-weighted fast-spin-echo imaging in the diagnosis of meniscal tears

The objective of this study was to compare the accuracy of T2-weighted fast-spin-echo (FSE) and intermediate-weighted spin-echo (SE) MR imaging in the detection of meniscal tears. Seventy-six patients (152 menisci) who had arthroscopic surgery after MR imaging of the knee were studied. MR imaging included intermediate-weighted SE and T2-weighted FSE sequences. The use of intermediate-weighted conventional SE images, T2-weighted FSE images, and a combination of both sequences were evaluated in the detection of meniscal tears. T2-weighted FSE imaging was slightly less accurate than intermediate-weighted SE imaging in the diagnosis of meniscal tears. Interpretation of the menisci using both intermediate-weighted SE and T2-weighted FSE imaging did not improve the accuracy over intermediate-weighted imaging evaluated in isolation.

Allele-specific replication of 15q11-q13 loci: a diagnostic test for detection of uniparental disomy

Allele-specific replication differences have been observed in imprinted chromosomal regions. We have exploited this characteristic of an imprinted region by using FISH at D15S9 and SNRPN (small nuclear ribonucleo protein N) on interphase nuclei to distinguish between Angelman and Prader-Willi syndrome patient samples with uniparental disomy of chromosome 15q11-q13 (n = 11) from those with biparental inheritance (n = 13). The familial recurrence risks are low when the child has de novo uniparental disomy and may be as high as 50% when the child has biparental inheritance. The frequency of interphase cells with asynchronous replication was significantly lower in patients with uniparental disomy than in patients with biparental inheritance. Within the sample population of patients with biparental inheritance, those with altered methylation and presumably imprinting center mutations could not be distinguished from those with no currently detectable mutation. This test is cost effective because it is performed on interphase cells from the same hybridized cytological preparation in which a deletion is excluded, and additional specimens are not required to determine the parental origin of chromosome 15.

Does altered biomechanics cause marrow edema?

PURPOSE

To determine if altered weight bearing causes the appearance of marrow edema on magnetic resonance (MR) images.

MATERIALS AND METHODS

Twelve volunteers underwent MR imaging with a short inversion time inversion-recovery (STIR) sequence at 1.5 T. The hips, knees, ankles, and feet were evaluated before and 2 weeks after altered weight bearing achieved with overpronation of one foot. Three volunteers underwent imaging a third time, 2 weeks after overpronation was stopped. Two observers assessed the images for evidence of marrow edema.

RESULTS

Changes were seen on images in 11 volunteers; the overpronated side only was affected in 10. Most changes occurred in the foot followed by the tibia and the femur. Most changes were a diffuse increase in marrow edema. In two volunteers, the changes resembled those of stress fractures.

CONCLUSION

Altered weight bearing should be added to the list of causes of increased medullary signal intensity (ie, marrow edema) on MR images.

Enlargement of the third intercondylar tubercle of Parsons as a sign of osteoarthritis of the knee: a paleopathologic and radiographic study

PURPOSE

To correlate presence and size of the third intercondylar tubercle of Parsons (TITP) with occurrence and severity of osteoarthritis of the knee.

MATERIALS AND METHODS

In 100 paleopathologic tibial specimens and on 160 clinical knee radiographs, size of the TITP was correlated with osteoarthritis of medical and lateral femorotibial joints (FTJ) and with prominence of tibial spines.

RESULTS

TITP size correlated significantly with osteoarthritis of the tibial plateau in the paleopathologic specimens (P<.0001). TITP size correlated significantly with osteoarthritis of medial FTJ and tibial spines on radiographs (P<.0001). Of 85 patients without osteoarthritis of the medial FTJ, 49 (58%) had no TITP, 33 (39%) had small TITPs, and three (4%) had medium or large TITPs. TITPs were found in 15 (88%) of 17 patients with pronounced osteoarthritis.

CONCLUSION

Frequency and prominence of TITPs are increased in patients with osteoarthritis of the medial FTJ and prominent tibial spines. Prominent TITP is a secondary sign of osteoarthritis. At histologic examination, increasing size of TITPs represents osteophytosis or enthesopathy of the TITP.

Exacerbation of congestive heart failure after administration of polyethylene glycol-electrolyte lavage solution

OBJECTIVE

To report a patient with exacerbation of congestive heart failure after administration of polyethylene glycol-electrolyte lavage solution (PEG-ELS).

METHODS

A MEDLINE search was performed, using the terms congestive heart failure (CHF), gastric lavage, colonoscopy, irrigation, and gastroparesis, of English-language articles published from January 1980 through January 1995, as well as review of pertinent articles' bibliographies.

CASE SUMMARY

A 45-year-old white woman with left ventricular systolic dysfunction and diabetic gastroparesis received 4 L of a PEG-ELS as preparation for colonoscopy. Within 24 hours she presented to the emergency department with shortness of breath and increased bilateral lower extremity edema. She was admitted and treated with intravenous furosemide therapy. After aggressive diuresis her symptoms returned to baseline and she was discharged.

DISCUSSION

The literature search revealed no report of a patient requiring hospitalization as a result of sodium and water retention after bowel preparation with PEG-ELS. CHF is not considered a contraindication to the use of this solution; however, most studies that included patients with heart failure did not describe the degree of left ventricular dysfunction. Our patient's severe CHF, in combination with chronic renal insufficiency, resulted in significant retention of sodium and water.

CONCLUSIONS

Patients with severe left ventricular dysfunction and chronic renal insufficiency who are being considered for procedures that necessitate bowel cleansing with PEG-ELS may be at risk for sodium and water retention and exacerbation of CHF.

Study of osteomyelitis: utility of combined histologic and microbiologic evaluation of percutaneous biopsy samples

PURPOSE

To determine the utility of combined histologic and microbiologic evaluation of percutaneous biopsy samples in cases of suspected osteomyelitis.

MATERIALS AND METHODS

Twenty-five patients with suspected osteomyelitis were prospectively studied over a 1-year period. With usual trephine techniques under radiologic guidance, core and aspiration biopsy samples were obtained in each patient for both histologic and microbiologic analyses.

RESULTS

Sixteen biopsy specimens demonstrated histologic evidence of osteomyelitis. Of these, eight were also culture positive. Seven of the eight culture-negative, histologically positive cases were interpreted as chronic osteomyelitis. In no patient were cultures positive and histologic findings negative. Three of 19 patients with proved osteomyelitis had negative histologic and microbiologic findings. The sensitivity of culture in the diagnosis of osteomyelitis in our study was 42%; the sensitivity of both culture and histologic findings was 84%.

CONCLUSION

Although the volume of a biopsy specimen is a major determinant of culture yield, a portion of a percutaneous biopsy sample should be histologically evaluated for possible osteomyelitis.

Doppler sonography of adnexal masses: the predictive value of the pulsatility index in benign and malignant disease

OBJECTIVE

The purpose of this study was to determine whether pulsed Doppler sonography can be used to distinguish between benign and malignant adnexal masses on the basis of pulsatility index.

SUBJECTS AND METHODS

In an 18-month period, all patients in whom an adnexal mass was detected at sonography had further evaluation of the mass by color and pulsed Doppler sonography. Ninety-nine patients with 102 masses that were surgically removed were included in the study. The pulsatility indexes were calculated from the reproducible spectral waveforms generated from flow centrally or peripherally within or immediately adjacent to the mass. Each lesion was categorized on the basis of its gray scale morphologic features as typically benign or indeterminate/malignant in appearance.

RESULTS

Of the 102 adnexal masses, 89 were benign and 13 were malignant. In seven of the 89 benign lesions, no flow could be detected, and these were excluded from analysis. Of the remaining 82 benign lesions, 65 showed pulsatility indexes consistently equal to or greater than 1.0, and 17 showed pulsatility indexes of less than 1.0. Ten of the 13 malignant lesions had pulsatility indexes consistently less than 1.0, and three primary malignant tumors had their lowest pulsatility indexes ranging between 1.1 and 1.8. Sixty-five of the 68 masses with pulsatility indexes equal to or greater than 1.0 were benign, for a positive predictive value of 96% for benign disease. Ten of the 27 masses with pulsatility indexes of less than 1.0 were malignant, for a positive predictive value of 37% for malignant disease. Forty-five masses were detected in perimenopausal and postmenopausal patients. In this group, the pulsatility index had a positive predictive value of 88% for benign disease and 47% for malignant disease. In this study, 45 of 49 masses that had a typically benign sonographic appearance had pulsatility indexes equal to or greater than 1.0. All 49 masses had benign histology. In the remaining 46 masses with an indeterminate/malignant sonographic appearance, 20 of 23 with pulsatility indexes equal to or greater than 1.0 were benign, and 10 of 23 with pulsatility indexes of less than 1.0 were malignant.

CONCLUSION

Our results show a high positive predictive value of high-impedance flow in benign adnexal disease and a predominance of low-impedance flow in malignant adnexal disease. However, the pulsatility indexes showed considerable overlap between benign and malignant lesions, indicating that Doppler sonography has severe limitations in the differentiation of benign from malignant adnexal disease on the basis of low-impedance flow (pulsatility index < 1.0).

Scintigraphic flare in skeletal lymphoma

The authors describe the bone scan flare phenomenon in a patient with treated skeletal lymphoma. This was confirmed by both gallium scanning and computed tomography. If serial bone scintigraphy is used for assessing the treatment response of lymphoma, the flare phenomenon must be recognized.