M. Cammisa

Measurement of bone mineral density at the spine and proximal femur by volumetric quantitative computed tomography and dual-energy X-ray absorptiometry in elderly women with and without vertebral fractures.

The goal of this study was to determine the effect of vertebral fracture status on trabecular bone mineral density (BMD) measurements obtained in the proximal femur and spine by helical volumetric quantitative computed tomography (vQCT). The study population consisted of 71 Italian women (average age 73 +/- 6) years. This group included 26 subjects with radiographically confirmed atraumatic vertebral fractures and 45 controls. The subjects received helical CT scans of the L1 and L2 vertebral bodies and the hip. The three-dimensional CT images were processed using specialized image analysis algorithms to extract measurements of trabecular, cortical, and integral BMD in the spine and hip. To compare the vQCT results with the most widely used clinical BMD measurement, dual X-ray absorptiometry (DXA) scans of the anteroposterior (AP) spine and proximal femur were also obtained. The difference between the subjects with vertebral fractures and the age-matched controls was computed for each BMD measure. All BMD measurements showed statistically significant differences, which ranged from 7% to 22% between subjects with fractures and controls. Although, given our small sample size, we could not detect statistically significant differences in discriminatory power between BMD techniques, integral BMD of the spine measured by vQCT and DXA tended to show stronger associations with fracture status (0.001 < p < 0.004). Measurements by QCT and DXA at the hip were also associated with vertebral fracture status, although the association of DXA BMD with fracture status was explained largely by differences in body weight between subjects with vertebral fractures and controls.

Diffuse idiopathic skeletal hyperostosis.

OBJECTIVE To describe the axial and appendicular skeleton findings of diffuse idiopathic skeletal hyperostosis. To analyze the role of conventional radiography, computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis of this condition. To discuss the differential diagnosis and diagnostic pitfalls of this disease. MATERIAL AND METHODS The involvement of vertebral and extravertebral sites including the pelvis, calcaneum, ulnar olecranon, and patella is frequently found in the literature. The lesions described are the anterior and lateral ossification of the spine, hyperostosis at sites of tendon and ligament insertion, ligamentous ossification, and periarticular osteophytes. The criteria for the diagnosis of diffuse idiopathic skeletal hyperostosis involving the spine are: flowing ossification along the anterior and anterolateral aspects of at least four contiguous vertebrae, preserved intervertebral disc height, no bony ankylosis of the posterior spinal facet joints, and finally no erosion, sclerosis or bony ankylosis of the sacroiliac joints. RESULTS The disease has about the same frequency in men (65%) and women (35%); it is most common in the thoracic spine and occurs less frequently in the lumbar and cervical spine. The disease most commonly presents in the sixth and seventh decades of life and its estimated frequency in the elderly is 5-15%. Signs and symptoms include stiffness and pain in the back, dysphagia due to direct esophageal compression/distorsion, pain related to associated tendinitis, myelopathy related to core compression associated to the ossification of the posterior longitudinal ligament, and pain related to vertebral complications--e.g. fracture/subluxation. CONCLUSION While conventional radiography clearly confirms the diagnosis of diffuse idiopathic skeletal hyperostosis, CT and MRI better detect associated findings (e.g. ossification of the posterior longitudinal ligament) and complications (e.g. spinal cord compressive myelomalacia).

Palangeal Quantitative Ultrasound, Phalangeal Morphometric Variables, and Vertebral Fracture Discrimination

The aim of this study was to evaluate the association among phalangeal morphometric parameters, amplitude-dependent speed of sound (AD-SOS), ultrasound bone profile index (UBPI), and spinal bone mineral density (BMD) and fracture status. One hundred women (controls, mean age 53 ± 12 years) and 40 osteoporotic women (mean age 59 ± 7 years) with atraumatic fractures, diagnosed by spinal radiographs, were investigated. Quantitative ultrasound (QUS) assessment was performed using the DBM Sonic 1200. Morphological properties of the phalanges were measured from a digitized X-ray image of the hand acquired using industrial film. Spinal BMD was assessed by dual X-ray absorptiometry (DXA) and quantitative computed tomography (QCT). An increase in medullary canal width and a decrease in cortical thickness with aging were observed from the morphometric analysis of the hand radiographs. This phenomenon can be attributed mainly to endosteal resorption. QUS measurements at the phalanges were not significantly related to finger thickness (r <0.20, n.s.). They were significantly correlated to medullary canal ratio (r = -0.57, P <0.0001, for AD-SOS and r = -0.64, P <0.0001, for UBPI) and to cortical thickness (r = +0.52, P <0.0001 for AD-SOS and r = +0.59, P <0.0001 for UBPI). In the discrimination analysis between nonfractured and atraumatic vertebral fracture subjects we found that cortical thickness at the level of the phalanges were similar to lumbar spine BMD. The age and BMI-adjusted odds ratio ranged from 2.0 to 3.1 for QUS, 4.28 for BMD by QCT, 4.1 for BMD by DXA, and 4.1 for cortical thickness. We conclude from these data that phalangeal QUS is related to cortical thickness, which in turn is influenced by endosteal bone resorption occurring in association with spinal osteoporosis.

Congenital Absence of the Internal Carotid Artery

Abstract We report three cases of congenital absence of an internal carotid artery (ICA), diagnosed incidentally by digital subtraction angiography. The analysis of the cases is based on the classification of segmental ICA agenesis proposed by Lasjaunias and Berenstein. Usually the patients with this rare vascular anomaly are asymptomatic; some may have symptoms related to cerebrovascular insufficiency, compression by enlarged intracranial collateral vessels, or complications associated with cerebral aneurysms. Diagnosis of congenital absence of ICA is made by skull base computed tomography (CT) scan, CT and magnetic resonance angiography, and conventional or digital subtraction angiography.

Phalangeal US velocity discriminates between normal and vertebrally fractured subjects.

Abstract. The purpose of this study was to evaluate the diagnostic sensitivity of phalangeal bone ultrasound velocity of the hand in the diagnosis of osteoporosis and to compare this technique to bone mineral density (BMD) measurement at the lumbar spine assessed by dual X-ray absorptiometry (DXA) and quantitative computed tomography (QCT). We investigated US velocity at the distal metaphysis of the proximal phalanx and spinal BMD in 101 women. Fifty-nine were healthy (mean age 50 ± 11.6 years) and 42 were osteoporotic (mean age 65 ± 6.6 years) with documented vertebral fractures. In the healthy population the relation with age was, respectively, r = –0.73 (p < 0.0001) for quantitative US (QUS), r = –0.74 (p < 0.0001) for QCT and r = –0.48 (p < 0.01) for DXA. Both US and DXA were correlated with QCT: r = 0.74 and r = 0.77 (p < 0.0001), respectively. Correlation of QUS and DXA was r = 0.56 (p < 0.0001). Phalangeal US velocity and spinal BMD (QCT and DXA) values discriminate healthy from osteoporotic women. Age-adjusted logistic regression analysis of the data showed standardized odds ratios (OR) for vertebral fracture to be similar for US and DXA (OR = 1.8 and 1.5, respectively) and stronger for QCT (OR = 2.9). Phalangeal US velocity reflects age-related bone loss and differentiates between healthy and osteoporotic subjects.

Age-related changes assessed by peripheral QCT in healthy Italian women

Abstract. The purpose of this study was to describe the normal cross-sectional pattern of radial bone loss associated with aging in healthy women and to generate a normative database using peripheral quantitative computed tomography (pQCT). Subjects with suspected conditions affecting bone metabolism or receiving any drugs affecting bone mineralization were excluded. The trabecular bone mineral density (BMD) and the total bone density of the ultradistal radius at the nondominant forearm was measured using the Norland-Stratec XCT-960 pQCT scanner in 386 healthy pre-, peri-, and postmenopausal females aged 15–81 years. The long-term in vivo precision error was 1.6 % CV (coefficient of variation) for trabecular and 0.8 % CV for total BMD measurements. The highest value of trabecular and total BMD measured was observed at the age group 15–39 years. Beyond these ages both trabecular and total BMD showed a linear decline with aging, decreasing by an overall slope of −1.28 and −0.55 mg/cm3 per year for total and trabecular BMD measurements, respectively. The test of parallelism between the regression slopes of the peri- and postmenopausal women showed a statistically significant difference for total BMD measurement (p = 0.003). Measurement of total and trabecular BMD was not influenced by weight, height or body mass index, but it was correlated with natural logarithm of years since menopause. We conclude that pQCT of the ultradistal radius is a precise method for measuring the true volumetric BMD and for detecting age-related bone loss in the trabecular and total bone of female subjects encompassing the adult age range and menopausal status.

Erdheim-Chester disease: Clinical and pathologic spectrum of four cases from the Arkadi M. Rywlin Slide Seminars

Case 1 (contributed by M.B.) A man aged 44 years complained of a severe headache that had been present for a few months. Ten years previously, he had undergone surgical curettage of a lytic lesion in the mandible that was diagnosed as “histiocytosis X” (eosinophilic granuloma of bone). Five years before the current admission, he underwent another curettage of a lytic lesion in the scapula that was also diagnosed as histiocytosis X. On clinical examination, the patient exhibited unilateral right exophthalmus, and on investigation, diabetes insipidus was diagnosed. The T1-weighted gadoliniumenhanced MRI revealed a dural-based mass in the left temporal region compressing and superficially invading the temporal cortex (Fig. 1). In addition, there was abnormal tissue in the right retro-orbital region as well as expansile tumor masses in the pituitary-hypothalamic axis. The temporal lesion was excised, and on sectioning, there was a xanthogranulomatous reaction rich in foamy and eosinophilic histiocytes. Some were multinucleated, and a few were Touton in type. Lymphocytes and eosinophils were sprinkled throughout. The process involved the dura and the underlying cerebral tissue (Fig. 2). Immunohistochemically, the histiocytes were negative for S-100 protein and CD1a but positive for CD68 (clones KP-1 and PGM-1). No Birbeck granules were recognized on electron microscopy. The diagnosis rendered was “xanthogranulomatous inflammation.” Months later, radiographs revealed symmetric cortical osteosclerosis involving the metaphyses and diaphyses of the long bones of the upper and lower extremities (Figs. 3 and 4), and a final diagnosis of Erdheim-Chester disease was established.

Spinal bone mineral density by quantitative CT in a normal Italian population

The purpose of this study was to describe the normal cross-sectional pattern of spinal bone loss associated with aging in an Italian population and to compare these values to the American normative database. A group of 472 healthy subjects (382 females and 90 males) were recruited for bone mineral density (BMD) assessment by quantitative computed tomography (QCT). To eliminate technique-related differences in a comparison of Italian and American normal values obtained with two different scanners we performed a cross-calibration analysis scanning the same computerized imaging reference system (CIRS) phantom at both centers. The results of the cross-calibration study using the CIRS phantom were used to compare regression slopes of BMD with age and age-adjusted mean BMD of American men and women vs cross-calibrated Italian men and women. American men and women decrease more rapidly vs Italian men and women, and Italian men have significantly lower age-adjusted mean BMD than American men. For these reasons we recommend normal values to be locally obtained for an Italian population.

Treatment of hepatocellular carcinoma: a single-center experience.

PurposeThe comparative efficacy of transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in the treatment of hepatocellular carcinoma (HCC) was investigated.MethodsTwo hundred and sixty consecutive patients were retrospectively analyzed: 156 had received between one and six chemoembolization sessions at 3-month intervals, 33 had had PEI, and the remaining 71 patients refused any treatment. The follow-up ranged from 3 to 36 months. Survival rates were statistically analyzed by life-table analysis.ResultsPatients’ survival was affected by the number of nodules and by the Child’s and Okuda’s classes; no relationship was found between survival rates and the histologic grade or vascular supply of the tumor. In the case of a single lesion of Okuda’s class I, TACE was more effective than PEI. In multifocal HCC, TACE was better than no treatment in Okuda’s class I and Child’s class A.ConclusionWe suggest TACE as the treatment of choice in Child A or Okuda I patients with multifocal HCCs; it seems of little help in Child B-C or Okuda II–III patients.

Bone Densitometry and Osteoporosis at the Hand and Wrist

Osteroporosis is one of the most devastating disorders associated with aging. The disease is characterized by decreased bone mineral density (BMD) and microarchitectural deterioration in bone tissue, resulting in an increased risk of atraumatic fracture. In the preclinical state the disease is characterized simply by low bone mass without fractures. This totally asymptomatic state is often termed “osteopenia” [1]. Osteoporosis and osteropenia are the most common metabolic bone diseases in the developed countries [2]. In order to be able to evaluate more completely the prevalence and incidence of osteoporosis, the World Health Organization (WHO) convened an expert panel to define osteoporosis on the basis of bone mass measurement [3]. The diagnostic categories for women that were established by that panel are as follows: