Contrast-enhanced imaging in hepatic epithelioid hemangioendothelioma: retrospective study of 10 patients.

PURPOSE: The purpose of this study was to analyze imaging findings in hepatic epithelioid hemangioendothelioma (HEHE) with a particular focus on contrast-enhanced ultrasound (CEUS). MATERIALS AND METHODS: This retrospective multicenter study included 10 patients with histologically proven HEHE from 5 European centers. All existing ultrasound images/videos were independently analyzed by 2 experienced examiners (DEGUM level III, internal medicine) using a standardized evaluation form. Patterns of contrast enhancement were correlated with computed tomography (CT), magnetic resonance imaging (MRI), and pathological findings. RESULTS: B-mode ultrasound, CEUS, CT, and MRI were performed in 90 %, 70 %, 100 %, and 90 % of patients, respectively. Multifocal HEHE could be observed in 80 % with affection of both liver lobes in 70 %. Analysis of CEUS revealed 3 characteristic patterns that correlated well with contrast patterns on CT and MRI: (a) peripheral nodular enhancement with centripetal fill-in and wash-out in the portal venous and late venous phase (PVLP), (b) rim-like arterial enhancement with wash-out in the PVLP, and (c) inversed target sign with/without wash-out in the PVLP. Wash-out in the PVLP as a sign suspicious of malignancy was observed in 6/7 patients (85.7 %). CONCLUSIONS: Knowledge of the different characteristic CEUS patterns is of importance to avoid misdiagnosis due to resemblance of patterns A and B to the much more common focal liver lesions hemangioma and intrahepatic cholangiocarcinoma. Of importance, sonographers should be aware that wash-out in the PVLP might be absent in some patients.

Diagnosis of Richter transformation in chronic lymphocytic leukemia: histology tips the scales.

Development of diffuse large B-cell lymphoma in chronic lymphocytic leukemia, so-called Richter transformation (RT), occurs in 2-5% of patients and is associated with poor outcome. The clinical features of RT are fairly non-specific and unable to discriminate transformation from other mimics. In case of clinically suspected RT, a CT/MRT is recommended, and FDG-PET/CT may help to select the site of biopsy. Radiological features suggestive of RT have been defined, but there are only limited data about their predictive value, and histological confirmation is still considered the gold standard for RT diagnosis. We retrospectively analyzed 34 patients with clinically suspected RT and available radiological and histological data. A histopathological diagnosis of RT with concordant clinical and radiological findings was obtained in 13 patients. In 18 patients, CT did not show features of transformation, concordant with lack of RT in the biopsy. Of interest, a distinct lymphoma other than DLBCL was identified in two of these cases. A false-positive radiological diagnosis of RT was rendered in two patients, including a case of Herpes simplex virus lymphadenitis. In conclusion, our findings confirm the central role of tissue biopsy in the diagnostic work up in case of clinically suspected RT.

Cardiovascular magnetic resonance patterns of biopsy proven cardiac involvement in systemic sclerosis.

BACKGROUND: To determine morphological and functional cardiovascular magnetic resonance (CMR) patterns in histopathologically confirmed myocardial involvement in patients with systemic sclerosis (SSc). METHODS: Twenty patients (6 females; mean age 41 ± 11 years) with histopathologically proven cardiac involvement in SSc in the years 2008-2016 were retrospectively evaluated. Morphological, functional and late gadolinium enhancement (LGE) images were acquired in standard angulations at 1.5 T CMR. Pathologies were categorized: 1) Pericardial effusion; 2) pathologic left (LV) or right ventricular (RV) contractility (hypokinesia, dyssynchrony, and diastolic restriction); 3) reduced left (LV-EF) and right ventricular ejection fraction (RV-EF); 4) fibrosis and/or inflammation (positive LGE); 5) RV dilatation. 95 % confidence intervals (CI) were calculated for appearance of pathologic EF and RV dilatation. RESULTS: Seven patients (35 %) had positive CMR findings in three categories, 9 patients (45 %) in four categories and 4 patients (20 %) in five categories. The distribution of pathologic findings was: minimal pericardial effusion in 7 patients (35 %), moderate pericardial effusion >5 mm in nine patients (45 %); abnormal LV or RV contractility in 19 patients (95 %), reduced LV or RV function in 14 patients (70 %; 95 % CI: 51-88 %), pathologic LGE in all patients, RV dilatation in 6 patients (30 %; 95 % CI: 15-54 %). CONCLUSIONS: CMR diagnosis of myocardial involvement in SSc requires increased attention to subtle findings. Pathologic findings in at least three of five categories indicate myocardial involvement in SSc.

Long-term survival correlates with immunological responses in renal cell carcinoma patients treated with mRNA-based immunotherapy.

Renal cell carcinoma (RCC) is an immunogenic tumor for which immunotherapeutic approaches could be associated with clinically relevant responses. It was recently shown, that induction of T-cell responses against multiple tumor-associated antigen (TAA) epitopes results in prolonged overall survival in RCC patients. In 2003-2005, we performed a phase I/II trial testing an mRNA-based vaccine formulation consisting of a mixture of in vitro transcribed RNA coding for six different TAAs (MUC1, CEA, Her2/neu, telomerase, survivin, MAGE-A1) in 30 metastatic RCC (mRCC) patients. In the first 14 patients, vaccinations were applied i.d. on days 0, 14, 28, and 42. In the consecutive 16 patients, an intensified protocol consisting of i.d. injections (daily on days 0-3, 7-10, 28, and 42) was used. After the respective induction periods, patients in both cohorts were vaccinated monthly until tumor progression. At survival update performed in July 2015, one of the 30 patients was still alive. One patient was lost to follow-up. Median survival of 24.5 mo (all patients) and 89 mo (favorable risk patients) exceeded predicted survival according to Memorial Sloan Kettering Cancer Center (MSKCC) risk score. Impressively, long-term survivors displayed immunological responses to the applied antigens while vice versa no patient without detectable immune response had survived more than 33 mo. The current survival update shows a clear correlation between survival and immunological responses to TAAs encoded by the naked mRNA vaccine. This is one of the first vaccination studies and the only RNA trial that reports on safety and efficacy after a follow-up of more than 10 y.

Dual-Energy Computed Tomography of the Knee, Ankle, and Foot: Noninvasive Diagnosis of Gout and Quantification of Monosodium Urate in Tendons and Ligaments.

Gout is a true crystal deposition arthropathy caused by the precipitation of monosodium urate into joints and periarticular soft tissues. It is the most common inflammatory arthropathy in men and women of older age with a male-to-female ratio of 3 to 8:1. The disease may progress from asymptomatic hyperuricemia through symptomatic acute gout attacks with asymptomatic periods into chronic symptomatic tophaceous gout. Although invasive arthrocentesis and demonstration of monosodium urate crystals on polarized light microscopy is definitive for the diagnosis of gout, dual-energy computed tomography (CT) allows for noninvasive visualization and reproducible volume quantification of monosodium urate crystals. Based on the high diagnostic performance, dual-energy CT has been included in the 2015 American College of Rheumatology/European League Against Rheumatism Collaborative Initiative Classification Criteria for Gout. Increasing evidence indicates the usefulness of dual-energy CT to guide the management of patients with suspected gout and monitor the effectiveness of urate-lowering medical therapy.

Explanations for the heterogeneity of splenic enhancement derived from blood flow kinetic measurements using dynamic contrast-enhanced CT (DCE-CT).

BACKGROUND: The heterogeneity of splenic computed tomography (CT) attenuation is still not fully understood. A differentiation of these enhancement patterns and other conditions such as diffuse spleen infiltration can be challenging. PURPOSE: To understand the underlying physiological mechanisms of flow heterogeneity in normal and cirrhosis patients by quantifying perfusion parameters such as blood flow (BF), blood volume (BV), time to peak (TTP), flow extraction product (K(trans)), and mean transit time (MTT) using dynamic contrast-enhanced CT (DCE-CT). MATERIAL AND METHODS: Sixteen patients without splenic or hepatic disease and 16 patients with liver cirrhosis were retrospectively analyzed. Perfusion assessment included rapidly and slowly enhancing areas of the spleen, the entire splenic volume, as well as intra- and inter-observer reliability analysis. RESULTS: Significant differences between rapidly and slowly enhancing areas were found in controls for BF (109.8 mL/100 mL/min vs. 63.5 mL/100 mL/min), BV (37.1 mL/100 mL vs. 18.9 mL/100 mL), MTT (10.1 s vs. 13.0 s), but not for TTP (17.6 s vs. 18.6 s) and K(trans) (40.3 mL/100 mL/min vs. 44.7 mL/100 mL/min). In cirrhotic patients, differences proved significant for BF (90.5 mL/100 mL/min vs. 58.7 mL/100 mL/min), BV (17.5 mL/100 mL vs. 8.8 mL/100 mL), but not for K(trans) (60.9 mL/100 mL/min vs. 50.5 mL/100 mL/min), TTP (18.8 s vs. 20.0 s), and MTT (11.4 s vs. 14.2 s). Differences between rapidly enhancing areas in controls and cirrhotic patients reached a significant level for BV and K(trans). CONCLUSION: Preliminary results suggest that DCE-CT-based splenic perfusion measurements enable detection of different blood flow kinetics presumed to represent the complex and characteristic architecture of splenic vascular channels. It is the separate analysis of flow kinetics through the rapidly enhancing channels that allow for additional differentiation between controls and patients with portal hypertension.

Imaging findings and therapy response monitoring in chronic sclerodermatous graft-versus-host disease: preliminary data of a simultaneous PET/MRI approach.

PURPOSE: Our objective was a multifunctional imaging approach of chronic sclerodermatous graft-versus-host disease (ScGVHD) and its course during therapy using PET/MRI. METHODS: We performed partial-body PET/CT and PET/MRI of the calf in 6 consecutively recruited patients presenting with severe ScGVHD. The patients were treated with different immunosuppressive regimens and supportive therapies. PET/CT scanning started 60.5 ± 3.3 minutes, PET/MRI imaging 139.5 ± 16.7 minutes after (18)F-FDG application. MRI acquisition included T1- (precontrast and postcontrast) and T2-weighted sequences. SUV(mean), T1 contrast enhancement, and T2 signal intensity from region-of-interest analysis were calculated for different fascial and muscular compartments. In addition, musculoskeletal MRI findings and the modified Rodnan skin score were assessed. All patients underwent imaging follow-up. RESULTS: At baseline PET/MRI, ScGVHD-related musculoskeletal abnormalities consisted of increased signal and/or thickening of involved anatomical structures on T2-weighted and T1 postcontrast images as well as an increased FDG uptake. At follow-up, ScGVHD-related imaging findings decreased (SUV(mean) n = 4, mean T1 contrast enhancement n = 5, mean T2 signal intensity n = 3) or progressed (SUV(mean) n = 3, mean T1 contrast enhancement n = 2, mean T2 signal intensity n = 4). Clinically modified Rodnan skin score improved for 5 follow-ups and progressed for 2. SUV(mean) values correlated between PET/CT and PET/MRI acquisition (r = 0.660, P = 0.014), T1 contrast enhancement, and T2 signal (r = 0.668, P = 0.012), but not between the SUV(mean) values and the MRI parameters. CONCLUSIONS: PET/MRI as a combined morphological and functional technique seems to assess the inflammatory processes from different points of view and provides therefore in part complementary information.

Correlation between [¹8F]FDG PET/CT and volume perfusion CT in primary tumours and mediastinal lymph nodes of non-small-cell lung cancer.

PURPOSE: The aim of this study was to investigate correlations between glucose metabolism as determined by [(18)F]FDG PET/CT and tumour perfusion as quantified by volume perfusion CT in primary tumours and mediastinal lymph nodes (MLN) of patients with non-small-cell lung cancer (NSCLC). METHODS: Enrolled in the study were 17 patients with NSCLC. [(18)F]FDG uptake was quantified in terms of SUVmax and SUVavg. Blood flow (BF), blood volume (BV) and flow extraction product (K(trans)) were determined as perfusion parameters. The correlations between the perfusion parameters and [(18)F]FDG uptake values were subsequently evaluated. RESULTS: For the primary tumours, no correlations were found between perfusion parameters and [(18)F]FDG uptake. In MLN, there were negative correlations between BF and SUVavg (r = -0.383), BV and SUVavg (r = -0.406), and BV and SUVmax (r = -0.377), but not between BF and SUVmax, K(trans) and SUVavg, or K(trans) and SUVmax. Additionally, in MLN with SUVmax >2.5 there were negative correlations between BF and SUVavg (r = -0.510), BV and SUVavg (r = -0.390), BF and SUVmax (r = -0.536), as well as BV and SUVmax (r = -0.346). CONCLUSION: Perfusion and glucose metabolism seemed to be uncoupled in large primary tumours, but an inverse correlation was observed in MLN. This information may help improve therapy planning and response evaluation.

Multifunctional profiling of non-small cell lung cancer using 18F-FDG PET/CT and volume perfusion CT.

UNLABELLED: The aim of this study was to investigate correlations between glucose metabolism registered by (18)F-FDG PET/CT and tumor perfusion quantified by volume perfusion CT and immunohistochemical markers Ki67 and microvessel density (MVD) in patients with non-small cell lung cancer (NSCLC). METHODS: Between February 2010 and April 2011, 24 consecutive patients (21 women, 3 men; mean age ± SD, 67.6 ± 6.8 y; age range, 55.6-81.3 y) with histologically proven NSCLC (14 adenocarcinoma, 9 squamous cell lung carcinoma [SCC], and 1 mixed adenocarcinoma and SCC) underwent (18)F-FDG PET/CT and additional volume perfusion CT. Maximum standardized uptake value (SUV(max)), mean SUV, and the metabolic tumor volume were used for (18)F-FDG uptake quantification. Blood flow (BF), blood volume (BV), flow extraction product (K(trans)), and standardized perfusion value (SPV) were determined as CT perfusion parameters. Both perfusion parameters and (18)F-FDG uptake values were subsequently related to the histologic subtypes, proliferation marker Ki67, MVD according to CD34 staining, and total tumor volume. RESULTS: Mean SUV, SUV(max), and the metabolic tumor volume (mL) were 5.8, 8.7, and 32.3, respectively, in adenocarcinoma and 8.5, 12.9, and 16.8, respectively, in SCC. Mean BF (mL/100 mL/min), mean BV (mL/100 mL), and K(trans) (mL/100 mL/min) were 35.4, 7.3, and 27.8, respectively, in adenocarcinoma and 35.5, 10.0, and 27.8, respectively, in SCC. Moderate correlations were found between the (18)F-FDG PET/CT parameters and Ki67 as well as between CT perfusion parameters and MVD but not vice versa. For all tumors, the following correlations were found: between SUV(max) and Ki67, r = 0.762 (P = 0.017); between SUV(max) and MVD, r = -0.237 (P = 0.359); between mean BF and Ki67, r = -0.127 (P = 0.626); and between mean BF and MVD, r = 0.467 (P = 0.059). Interestingly, correlations between the BF-metabolic relationship and total tumor volume were higher in SCC (r = 0.762, P = 0.017) than in adenocarcinoma (r = -0.0791, P = 0.788). CONCLUSION: (18)F-FDG uptake correlates with Ki67, whereas BF, BV, and K(trans) correlate with MVD. Therefore, (18)F-FDG uptake and perfusion parameters provide complementary functional information. An improved tumor profiling will be beneficial for both prognosis and therapy response evaluation in these tumors.

MDCT arthrography of the shoulder with datasets of isotropic resolution: indications, technique, and applications.

OBJECTIVE: The purposes of this review are to summarize the indications for MDCT arthrography of the shoulder, highlight the features of MDCT acquisition, and describe the normal and abnormal MDCT arthrographic appearances of the shoulder. CONCLUSION: MDCT arthrography is a valid alternative for shoulder imaging of patients with contraindications to MRI or after failed MRI. MDCT arthrography is accurate for assessment of a variety of shoulder abnormalities and, with further validation, may become the imaging test of choice for evaluation of the postoperative shoulder.

Assessment of splenic perfusion in patients with malignant hematologic diseases and spleen involvement, liver cirrhosis and controls using volume perfusion CT (VPCT): a pilot study.

RATIONALE AND OBJECTIVES: The aim of this study was to assess splenic perfusion in patients with spleen involvement in malignant hematologic diseases and liver cirrhosis and in controls without hepatosplenic disease using volume perfusion computed tomography. MATERIALS AND METHODS: Between October 2009 and December 2011, 14 hematologic patients with known spleen involvement were recruited. An additional 17 consecutive patients without known splenic or liver disease were enrolled as controls, as well as 29 patients with liver cirrhosis and portal hypertension. A 40-second volume perfusion computed tomographic scan of the upper abdomen was performed. Analysis included measurement of splenic volume, blood flow (BF), blood volume (BV), K(trans), and mean transit time (MTT). RESULTS: In lymphoma patients, mean splenic volume and perfusion parameters were as follows: splenic volume, 1125.34 mL; BF, 61.24 mL/100 mL/min; BV, 16.53 mL/100 mL; K(trans), 37.00 mL/100 mL/min; and MTT, 12.42 seconds. All perfusion values of patients with lymphoma and cirrhosis differed significantly, except for BV, compared to controls. For patients with lymphoma, significant correlations were found between splenic volume and BF (r = -0.683, P = .000), splenic volume and BV (r = -0.525, P = .002), and splenic volume and MTT (r = 0.543, P = .001). During treatment, significant correlations between the diameters of nodular lymphoma target lesions, splenic volume, and the perfusion parameters were present for splenic volume (r = 0.601, P = .002), BF (r = -0.777, P = .000) and BV (r = -0.500, P = .011). CONCLUSIONS: Volume perfusion computed tomography represents a novel tool for the assessment of splenic perfusion. Preliminary results in patients with spleen involvement reveal lower perfusion values compared to controls or patients with cirrhosis. Therefore, this technique might provide additional information in clinical routine.

Magnetic resonance imaging-guided osseous biopsy in children with chronic recurrent multifocal osteomyelitis.

PURPOSE: To report the safety and diagnostic performance of magnetic resonance (MRI)--guided core biopsy of osseous lesions in children with chronic recurrent multifocal osteomyelitis (CRMO) that were visible on MRI but were occult on radiography and computed tomography (CT). MATERIALS AND METHODS: A retrospective analysis of MRI-guided osseous biopsy performed in seven children (four girls and three boys; mean age 13 years (range 11 to 14) with CRMO was performed. Indication for using MRI guidance was visibility of lesions by MRI only. MRI-guided procedures were performed with 0.2-Tesla (Magnetom Concerto; Siemens, Erlangen, Germany; n = 5) or 1.5-T (Magnetom Espree; Siemens; n = 2) open MRI systems. Core needle biopsy was obtained using an MRI-compatible 4-mm drill system. Conscious sedation or general anesthesia was used. Parameters evaluated were lesion visibility, technical success, procedure time, complications and microbiology, cytology, and histopathology findings. RESULTS: Seven of seven (100%) targeted lesions were successfully visualized and sampled. All obtained specimens were sufficient for histopathological analysis. Length of time of the procedures was 77 min (range 64 to 107). No complications occurred. Histopathology showed no evidence of malignancy, which was confirmed at mean follow-up of 50 months (range 28 to 78). Chronic nonspecific inflammation characteristic for CRMO was present in four of seven (58%) patients, and edema with no inflammatory cells was found in three of seven (42%) patients. There was no evidence of infection in any patient. CONCLUSION: MRI-guided osseous biopsy is a safe and accurate technique for the diagnosis of pediatric CRMO lesions that are visible on MRI only.

Intraobserver and interobserver agreement of volume perfusion CT (VPCT) measurements in patients with lung lesions.

OBJECTIVES: To evaluate intraobserver and interobserver agreement of manually encompassed lung lesions for perfusion measurements using volume-perfusion computed tomography (VPCT). MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. HIPAA guidelines were followed. A 65-s dynamic study was acquired with scan parameters 80 kV, 60 mAs (80 mAs for patients ≥ 70 kg), 128 × 0.6mm collimation. Blood flow (BF), blood volume (BV) and K(trans) parameters were determined by syngo volume perfusion CT body with 88 lesions analyzed retrospectively. RESULTS: Within-subject coefficients of variation for intraobserver agreement (range 6.59-12.82%) were superior to those for interobserver agreement (range 21.75-38.30%). Size-dependent analysis revealed lower agreements for lesions <4 cm as compared to larger lesions. Additionally, agreements of the upper, middle and lower lung zones were different. CONCLUSIONS: Intraobserver agreement was substantial for VPCT lung cancer perfusion measurements encouraging the use for tumor characterization and therapy response monitoring. Interobserver agreement is limited and unexperienced readers should be trained before using this new method.

Intradermal vaccinations with RNA coding for TAA generate CD8+ and CD4+ immune responses and induce clinical benefit in vaccinated patients.

The aim of this phase I/II nonrandomized trial was to assess feasibility, safety as well as immunological and clinical responses of a mRNA-based vaccination in patients with stage IV renal cell cancer using granulocyte-macrophage colony stimulating factor (GM-CSF) as adjuvant. Intradermal injections of in vitro transcribed naked mRNA, which was generated using plasmids coding for the tumor-associated antigens mucin 1(MUC1), carcinoembryonic (CEA), human epidermal growth factor receptor 2 (Her-2/neu), telomerase, survivin, and melanoma-associated antigen 1 (MAGE-A1) were performed in 30 enrolled patients. In the first 14 patients (cohort A) vaccinations were administered on days 0, 14, 28, and 42 (20 µg/antigen) while in the consecutive 16 patients (cohort B) an intensified protocol consisting of injections at days 0-3, 7-10, 28, and 42 (50 µg/antigen) was used. In both cohorts, after this induction period, vaccinations were repeated monthly until tumor progression analyzed by Response Evaluation Criteria In Solid Tumors criteria (RECIST). Vaccinations were well tolerated with no severe side effects and induced clinical responses [six stable diseases (SD) and one partial response in cohort A and nine SD in cohort B]. In cohort A, 35.7% survived 4 years (median survival 24 months) compared to 31.25% in cohort B (median survival 29 months). Induction of CD4(+) and CD8(+) T cell responses was shown for several tumor-associated antigens (TAA) using interferon-γ (IFN-γ) enzyme-linked immunosorbent spot (ELISpot) and Cr-release assays.

MRI-guided injection procedures of the temporomandibular joints in children and adults: technique, accuracy, and safety.

OBJECTIVE: The purpose of our study was to test the hypothesis that real-time MRI-guided, selective injection procedures of the temporomandibular joints are feasible, accurate, and safe when performed on a clinical open-bore 1.5-T MR system. MATERIALS AND METHODS: A retrospective analysis of 67 injection procedures of the temporomandibular joints (55% [37/67] were therapeutic injections, 27% [18/67] were diagnostic injections, and 18% [12/67] were arthrocentesis procedures), performed in 31 patients (58% [18/31] female, 42% [13/31] male; mean age, 14 years; age range, 3-34 years), was made. Seven of 38 (18%) subjects had two temporally separate procedures. Determinations of skin entry points, puncture, and injection were performed under real-time MRI. Data were assessed for rate of successful injections, quantitative and qualitative image quality, time requirements, and occurrence of complications. RESULTS: Drug delivery was successful in all procedures. The quality of real-time FLASH 2D MR images was sufficient in all cases. Real-time MRI proved to be helpful to achieve high rates of intraarticular injections. Contrast-to-noise ratios were sufficiently high for good delineation of relevant structures. Average length of time was 25 minutes (range, 16-53 minutes). No major complications occurred. CONCLUSION: We accept the hypothesis that real-time MRI-guided selective injection procedures of the temporomandibular joints are feasible, accurate, and safe when performed on a clinical open-bore 1.5-T MR system.

Pathologic fractures in patients with multiple myeloma undergoing bisphosphonate therapy: incidence and correlation with course of disease.

OBJECTIVE: The purposes of this study were single-center analysis of the incidence of pathologic fractures in patients with multiple myeloma undergoing bisphosphonate therapy and correlation of the occurrence of pathologic fractures with the course of disease. MATERIALS AND METHODS: One hundred ninety-one patients with multiple myeloma consecutively underwent unenhanced whole-body low-dose MDCT in parallel with hematologic follow-up. Only patients undergoing at least two whole-body low-dose MDCT examinations were included in this retrospective study, resulting in 561 survey intervals. The median analysis period per patient was 23 months (range, 3-53 months). Fracture incidence and the relation between newly occurring fractures and course of the disease were assessed. RESULTS: Forty-nine pathologic fractures were detected in 49 of the 561 survey intervals (8.7%) and in 36 of the 191 patients (19%). Fractures were found on MDCT images irrespective of disease course. They were found in 25 of 202 intervals (12.4%) of progressive disease, in 14 of 171 intervals (8.2%) of disease remission, and in 10 of 188 intervals (5.3%) of stable disease. The overall calculated annual incidence of pathologic fractures in patients with multiple myeloma was 14%. Eleven patients had more than one fracture, all of which were vertebral compression fractures. Three patients had three episodes of bone fracture, and eight patients had two episodes. CONCLUSION: Pathologic fractures in patients with multiple myeloma undergoing bisphosphonate therapy occur independently of myeloma activity and therefore should not be considered a sign of disease progression.

Chronic recurrent multifocal osteomyelitis: comparison of whole-body MR imaging with radiography and correlation with clinical and laboratory data.

PURPOSE: To describe whole-body magnetic resonance (MR) imaging appearance of chronic recurrent multifocal osteomyelitis (CRMO) and assess the role of MR imaging versus radiography in diagnosis of disease and correlation with clinical findings and laboratory data. MATERIALS AND METHODS: Institutional review board approved this retrospective HIPAA-compliant study; informed consent was waived. T1-weighted, short inversion time inversion-recovery, and contrast material-enhanced T1-weighted whole-body MR imaging was performed and two-plane radiographs, clinical findings, and laboratory data were reviewed in 13 children (median age, 13 years) with CRMO. Lesion depiction, location, and characterization and extraskeletal abnormalities were evaluated. MR imaging findings were compared with clinical and laboratory data and radiographic results. Data analysis was performed, and diagnostic performance statistics of radiography, physical examination results, and serum inflammatory markers were calculated. General multilevel linear modeling framework was used. Odds ratios were calculated to estimate effect of age, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level on reliabilities. Associations of ESR and CRP level with total number of lesions were assessed (chi(2) test). RESULTS: MR imaging depicted 101 ill-defined edemalike osseous lesions. Most frequent anatomic sites were distal femur (21%, 21 of 101), proximal tibia (17%, 17 of 101), and distal tibia and fibula (14% each, 14 of 101). In tubular bones (70 anatomic sites), metaphysis (86%, 60 of 70) and epiphysis (67%, 47 of 70) were involved. Contiguous physeal relationship (89%, 66 of 74), periosteal reaction (48%, 48 of 101), and symmetric involvement (85%, 11 of 13) were present. MR imaging demonstrated multifocality in all patients. There were no extraskeletal abnormalities and no relationship between serum inflammatory markers and number of symptomatic anatomic sites (P = .472). Sensitivity for radiography was 0.13 (70 of 119); physical examination, 0.31 (52 of 299); and serum inflammatory markers, 0.15 (two of 13). CONCLUSION: Whole-body MR imaging is useful for detection of CRMO, particularly in indeterminate cases, because it is more likely to show abnormalities.

Longitudinal changes in rheumatoid arthritis after rituximab administration assessed by quantitative and dynamic contrast-enhanced 3-T MR imaging: preliminary findings.

We retrospectively assessed the longitudinal changes of rheumatoid arthritis under rituximab therapy by use of quantitative and dynamic contrast-enhanced 3-T magnetic resonance (MR) imaging of the metacarpophalangeal joints of 10 patients at baseline and 26 weeks (n = 10). Additional studies were available at 12 weeks (n = 9) and at 52 weeks (n = 5). Clinical activity was assessed by use of the 28-joint disease activity score (DAS28). MR imaging was used to assess volumes of synovial enhancement, osseous enhancement, and erosions and early rapid enhancement. DAS28 and serum C-reactive protein trended down over time and were significantly lower at 26 weeks. Volume of synovial enhancement and early rapid enhancement showed a significant minimum at 26 weeks and increased thereafter. The erythrocyte sedimentation rate paralleled these two trends. Osseous enhancement did not significantly change over time. Erosions showed a significant progression. Trends of DAS28 and erosions were significantly different (P = 0.0075). In conclusion, our preliminary results suggest that rituximab is associated with a decrease of the inflammatory activity of synovitis with a minimum at 26 weeks and increasing activity thereafter suggesting recurrence. Our results further suggest subclinical progression of erosions with an inverse relationship to decreasing disease activity scores. Further studies are needed to confirm these results.

Generalized intramuscular granulocytic sarcoma mimicking polymyositis.

We report a case of granulocytic sarcoma exclusively manifesting as diffuse intramuscular infiltration of the proximal upper and lower limb girdle and the torso muscles in a patient with previous history of acute myelogenous leukemia 5a. Whole-body CT showed widespread distribution of ill-defined intramuscular, homogeneously enhancing lesions. On whole-body MRI, lesions were homogeneously hyperintense on fat saturated T2-weighted images, isointense on T1-weighted images and strongly enhancing after intravenous gadolinium contrast administration. Histopathology revealed muscular infiltration of blast cells with identical immunochemistry to the initial manifestation of leukemia, diagnostic for an extramedullary relapse manifesting as granulocytic sarcoma. CT and MRI characteristics of this previously undocumented manifestation of granulocytic sarcoma should assist in the identification of such cases.