Cine MRI Is Useful for the Diagnosis of Intradural Arachnoid Cyst with Spinal Arachnoid Web: A Case Report.

CASE: A 28-year-old woman developed gait disturbance due to lower limb weakness 3 years before presentation. Conventional magnetic resonance imaging (MRI) findings were inconclusive; therefore, we performed cine MRI, which confirmed the presence of a pulsatile cyst on the posterior thoracic spinal cord. The cyst compressed the spinal cord, and its pulsations synchronized with the patient's heartbeats. We resected the intradural arachnoid cyst and thickened arachnoid membrane. The gait disturbance improved after surgery. CONCLUSIONS: Cine MRI can be used to identify a pulsating arachnoid cyst that cannot be visualized with a conventional MRI. Cine MRI is useful in patients with unexplained spinal symptoms.

Association of Magnetic Resonance Imaging Features with Angioleiomyoma Histologic Subtype.

BACKGROUND: Angioleiomyomas typically present as small, painful, soft-tissue tumors less than 2 cm in diameter. The features of angioleiomyomas on magnetic resonance (MR) imaging are not well understood, and the association of MR findings with histologic subtype is unclear. In the present study, the MR features of angioleiomyomas of average size were compared in relation to histologic subtype. METHODS: This retrospective review of medical records analyzed MR imaging data and histologic specimens from 18 consecutive patients with angioleiomyomas that were resected at our hospital during the period from January 2006 through December 2013. RESULTS: On T1-weighted images, lesions exhibited homogeneous areas that were isointense with skeletal muscle. However, T2-weighted images of solid and venous angioleiomyomas showed heterogeneous areas that were isointense or slightly hyperintense, while cavernous angioleiomyomas exhibited hyperintensity. Most lesions had a hypointense rim, and two thirds had adjacent vessels. CONCLUSIONS: Our results suggest that MR findings for angioleiomyoma vary in relation to histologic subtype. T2-weighted images of solid and venous angioleiomyomas yielded specific MR findings that allowed for differentiation from other soft-tissue tumors, such as soft-tissue sarcomas. Most of these tumors exhibited isointense to slightly hyperintense regions, as compared with skeletal muscle, while findings for cavernous angioleiomyomas were nonspecific. Thus, clinical findings and MR imaging were almost sufficient for preoperative diagnosis of solid and venous angioleiomyomas.

Effect of Orthopedics Promotional Activities on Multidisciplinary Management of Patients with Bone Metastases.

BACKGROUND: The rapid aging of the Japanese population is leading to an increase in the number of patients with bone metastases. Since 2014, our orthopedics department has promoted multidisciplinary hospital activities, including offering lectures to hospital staff on multidisciplinary approaches for bone metastases and holding regular cancer board meetings on bone metastases. This study investigated whether these activities were effective in promoting multidisciplinary approaches and improving outcomes of patients with bone metastasis. METHODS: To investigate the effects of changes in medical practice on patients with bone metastases, we compared patient clinical characteristics after (January 2014 through December 2017) and before the start of the activities (January 2011 through December 2013). RESULTS: The semiannual numbers of first-visit, referral, and orthopedic surgical patients, the number of patients with slower growing primary cancers, and the number of patients with milder pain were significantly higher post-activity than pre-activity. The number of patients without paralysis was higher after the start of the activity than before the activity, but the difference was not significant. Survival after the first visit to the orthopedics department was significantly longer after the start of the activity than before the activity. CONCLUSIONS: The potential demand for a multidisciplinary approach to bone metastases is high, and orthopedic specialists should actively participate in this approach.

Symptoms Related to Moderate Skeletal-Related Events as Clues for the Diagnosis of Bone Metastasis.

BACKGROUND: Early diagnosis of bone metastasis is difficult. The aim of the present study was to determine whether symptoms related to skeletal-related events (SREs) can be used for the diagnosis of bone metastasis in the absence of screening tests. METHODS: We reviewed 81 patients with bone metastasis to evaluate their SREs at diagnosis. SREs were arbitrarily classified as moderate or severe. Moderate SREs included radiation to the bone before pathological fracture or paralysis, bone surgery before pathological fracture or paralysis, and hypercalcemia without dialysis. Severe SREs included pathological fracture, spinal cord compression, and hypercalcemia necessitating dialysis. RESULTS: The complication rates of SREs at the time the bone metastasis was diagnosed were 59.3% and 24.7% for severe and moderate SREs, respectively, and only 16.0% of cases were uncomplicated. The clinical factors that showed a significant relationship with the severity of SREs were age and history of malignancy. However, there was no significant relationship between the complication rate of total SREs and the presence or absence of a malignancy history (83.3% vs. 85.2%, respectively, p=0.83). CONCLUSION: The results of the present study suggest that symptoms related to SREs can be used to diagnose bone metastasis in the absence of a screening test. Bone metastasis should be diagnosed as often as possible based on symptoms related to moderate SREs and should be treated as soon as possible before patients develop severe SREs.

Development and Verification of Educational Material for Plain Radiographic Diagnosis of Bone Metastasis: A Preliminary Report.

Our previous studies showed that early diagnosis of painful bone metastasis is difficult and requires improvement in the diagnostic accuracy of plain radiography during an initial patient consultation. In this preliminary study, we evaluate the usefulness of educational material used to improve diagnosis of bone metastasis with plain radiography. This study included imaging data from 129 consecutive patients who visited our orthopedic clinic during the period January 2011 through December 2014. First, we prepared a test to measure the reading ability of orthopedic practitioners, after which the educational material was created. Then, the effectiveness of the educational material was verified by having orthopedic trainees take a pre-test and post-test. The test contained plain radiographic data from 12 patients with lesions and 6 without lesions. The educational material included plain radiographic data from 30 patients with typical findings of bone metastasis, as well as diagnostic magnetic resonance images or computed tomography scans, accompanied by a lecture. The accuracy and sensitivity of diagnosis significantly improved after the lecture; however, specificity decreased. Although the educational material was effective for improving the ability of orthopedic trainees to read plain radiographs of bone metastasis, some aspects of the program need to be improved and revised.

Diagnosis of Bone Metastasis in Patients Without a History of Cancer.

BACKGROUND: Diagnosing bone metastasis in patients without a history of cancer remains challenging. Diagnostic evaluation may be prolonged owing to difficulties in distinguishing between bone metastasis and common orthopedic diseases. We hypothesized that bone metastasis due to occult cancer would be more difficult to diagnose than bone metastasis in patients with a history of cancer. Few studies exist on the difficulty of diagnosing bone metastasis in patients without a history of cancer. Therefore, we reviewed the clinical course of patients with bone metastasis between January 2011 and December 2014. METHODS: We reviewed patients with bone metastasis to determine the diagnostic rate at first visit, period from symptom-onset to first visit, period from first visit to diagnosis, and presence of severe skeletal-related events at diagnosis, and compared these between 27 patients without a history of cancer (Group A) and 54 patients with a history of cancer (Group B). RESULTS: The diagnostic rate at first visit was significantly lower (11.5% vs. 52.4%, p=0.00069), the period from first visit to diagnosis was significantly longer (median, 7 weeks vs. 3 weeks, p=0.018), and the presence of severe skeletal-related events at diagnosis was significantly higher (81.4% vs. 50.0%, p=0.05) in patients without a history of cancer compared with those with a history of cancer. CONCLUSIONS: The results of this study indicate that it is difficult to diagnose bone metastasis in patients without a history of cancer. This must be considered in the early diagnosis of bone metastasis to prevent severe skeletal-related events.

Diagnostic Value of Plain Radiography for Symptomatic Bone Metastasis at the First Visit.

BACKGROUND: To prevent and minimize skeletal-related diseases, early diagnosis of bone metastases is important. However, previous reports have shown that plain radiography has low sensitivity and fails to screen multiple asymptomatic lesions. Limited investigations have been reported on the value of plain radiography in the diagnosis of symptomatic bone metastases. Therefore, this study aimed to investigate the diagnostic utility of plain radiography for symptomatic bone metastasis. METHODS: Two experienced orthopedic surgeons retrospectively evaluated the plain radiographs of 39 patients with symptoms during their first visit between 2011 and 2014 for bone metastases. Another 2 experienced orthopedic surgeons then reviewed the data using 2 reference standards, the clinical results and the retrospectively evaluated results, in a blinded manner. The data were then reviewed by 2 certified orthopedic surgeons and 7 orthopedic surgeons in training with differing years of experience in a blinded manner. RESULTS: The overall sensitivity of diagnosis of symptomatic bone metastasis using plain radiography at the clinic first visit was 71.4%. Upon blinded evaluation, the accuracy, sensitivity, and specificity were 55.8%, 54.3%, and 68.8% and 77.6%, 73.0%, and 85.7% for clinical results and results from 2 experienced orthopedic surgeons as a reference standard, retrospectively. There was a strong and significant correlation between the accuracy and observers' years of experience in orthopedic surgery among the orthopedic surgeons in training (R=0.942, p=0.0015). CONCLUSIONS: Plain radiography around the time of the first visit has a definitive role in the early diagnosis of symptomatic bone metastasis.

Challenges in the Diagnosis of bone Metastasis in Patients without a History of Malignancy at Their First Clinic Visit.

BACKGROUND: Many patients with bone metastases whose diagnoses came only after they had suffered aggravated conditions are still frequently encountered. However, there have been few studies regarding the early diagnosis of such metastases. We retrospectively reviewed the clinical courses of cases we experienced between 2004 and 2014 to clarify the practical situation of diagnosis of such bone metastases. METHODS: We undertook a retrospective review of 56 of our patients with bone metastasis who had no history of malignancy at their first visit, who visited our departments between 2004 and 2014. The initial diagnoses at the first visit to any clinic, the period from the first visit to any clinic to diagnosis of bone metastasis, the process to make the diagnosis, the frequency of severe skeletal-related events at diagnosis, and the examination serving as the basis for diagnosis were evaluated. RESULTS: The diagnosis of bone metastasis was made at the first visit in only 6 of the 56 patients. Pathological fractures, paralysis and/or calcemia were seen in 62.5% of the patients at diagnosis of bone metastasis. The median period from the first visit to any clinic to diagnosis was 7.0 weeks. Typically, the diagnosis of bone metastasis was made only after aggravation. The most frequent examination to serve as the basis of diagnosis was magnetic resonance imaging. CONCLUSIONS: Diagnosis of bone metastasis is challenging in patients without a history of malignancy at their first visit. For early diagnosis, it is important to recognize this challenge and to keep it in mind together with ongoing observation.

Intercondylar fracture of the distal humerus in a 7-year-old child: A case report and a review of the literature.

RATIONALE: Intercondylar fracture of the distal humerus is an extremely rare injury in children, especially in those under 8 years of age. To our best knowledge, there have been 55 reported cases of this fracture type in children in the English literature, 12 of which involved children under 8 years of age. PATIENT CONCERNS: We report a case of intercondylar fracture of the distal humerus in a7-year-old boy fell in a gymnasium, injuring his left elbow. INTERVENTIONS: Closed reduction was initially attempted under fluoroscopic guidance, but anatomic reduction could not be achieved because the fragments were extremely unstable and irreducible. Considering the displacement and the failure of closed reduction, ORIF through a posterior approach was performed. Open reduction and double cross-pinning across the medial and lateral condylar fragments were performed through a posterior approach. DIAGNOSES: Plain radiographs showed a displaced intercondylar fracture of the distal humerus. Arthrography under general anesthesia showed a severely displaced intra-articular fracture, with rotational displacement of the lateral condyle. OUTCOMES: Thirteen months after surgery, there was no functional disturbance or radiographic evidence of avascular necrosis or epiphyseal growth arrest. LESSONS: Open reduction and double cross-pinning through a posterior approach can be a reliable procedure for intercondylar fracture of the distal humerus in children.

Association of a single-nucleotide variation (A1330V) in the low-density lipoprotein receptor-related protein 5 gene (LRP5) with bone mineral density in adult Japanese women.

Low-density lipoprotein receptor-related protein 5 (LRP5), a co-receptor of Wnt signaling, is an important regulator of bone development and maintenance. Recently we identified correlation between an intronic single-nucleotide polymorphism (SNP) in the LRP5 gene and vertebral bone mineral density (BMD), indicating that a genetic ground exists at this locus for determination of BMD. In the study reported here, we searched for nucleotide variation(s) that might confer susceptibility to osteoporosis among an extended panel of 387 healthy subjects recruited from the same hospital (Group-A), as well as among 384 subjects from the general population in eastern Japan (Group-B). We basically focused on two potentially functional variations, Q89R (c.266A > G) and A1330V (c.3989C > T), whose functional effects by the amino-acid changes were estimated by the SIFT software program; it predicted the 1330 V allele as deleterious ("intolerant") although the minor allele of Q89R was questionable. By analyzing associations between the variant alleles and the BMD, reproducible association of the minor variant of A1330V to lower adjusted BMD levels was detected; i.e., In Group-A subjects 1330-V significantly associated with the spinal BMD Z-score (P = 0.034), and in Group-B it associated with low radial BMD (P = 0.019). From haplotype and linkage disequilibrium (LD) analysis for 29 SNPs, we detected two separate LD blocks within the entire 137-kb LRP5 locus, basically consistent with a previous report on Caucasians. One of the second block haplotype significantly associated with adjusted BMD (r = 0.15, P = 0.004). Possible combined effect of Q89R and A1330V belonging to different LD blocks was denied by multiple regression analyses. Our results indicate that genetic variations in LRP5 are important factors affecting BMD in adult women and that 1330 V may contribute to osteoporosis susceptibility, at least in Japanese.

Association of single nucleotide polymorphisms in the promoter region of the pro-opiomelanocortin gene (POMC) with low bone mineral density in adult women.

Among multiple factors influencing osteoporosis, genetic variations involved in bone-mineral metabolism can affect risks predisposing to the disease onset. Here, we studied single-nucleotide polymorphisms (SNPs) in the pro-opiomelanocortin (POMC) gene for possible association with bone mineral density (BMD) among 384 adult Japanese women and observed significant correlation between adjusted BMD and three SNPs in the promoter region (r>0.14, p<0.01). The most significant correlation was observed for -2353G/A (r=-0.16, p=0.002); homozygous carriers of the major (G) allele had the highest BMD (0.405+/-0.054 g/cm2) while heterozygous carriers were intermediate (0.390+/-0.053 g/cm2) and homozygous A-allele carriers had the lowest BMDs (0.369+/-0.048 g/cm2). Although no association was detected between these SNPs and body weight or body mass index (BMI), significant association was detected between the -2313A/C genotype and plasma total cholesterol level (r=-0.12, p=0.019). We propose that POMC is among the likely susceptibility genes for osteoporosis and may also be involved in dyslipidemia.