Nabil J. Khoury

Juvenile ossifying fibroma: CT and MR findings

Abstract. We describe the CT findings in four patients and the MR imaging in one patient with juvenile ossifying fibroma. Three lesions involved the maxillary sinus and extended to the surrounding structures; one lesion was confined to the maxillary bone. CT scan revealed well-defined, expansile lesions with variable amount of calcifications. On MRI one lesion had intermediate signal intensity with significant contrast enhancement.

Metastastic rhabdomyosarcoma to the breast

Abstract Rhabdomyosarcoma is a common extramammary primary malignancy in childhood that rarely metastasises to the breast. We present a patient with primary sinonasal rhabdomyosarcoma who was in remission when she developed breast metastases. We describe particular imaging findings of this disease, using ultrasound and MR imaging. To our knowledge, MR findings have only been described in one previous case report in the literature.

Abdominal Manifestations of Multiple Myeloma : A Retrospective Radiologic Overview

BACKGROUND Abdominal manifestations of multiple myeloma (MM) are rare. Herein, the authors study the radiologic characteristics of such involvement because these findings are usually missed by the radiologist and oncologist. PATIENTS AND METHODS We retrospectively reviewed the medical records of 202 patients with MM treated at our institution. A total of 192 patients underwent > or = 1 abdominal imaging studies (ultrasound, computed tomography, magnetic resonance imaging), which were correlated with histopathology, when available. RESULTS Eleven patients (5.72%) had lesions within 13 abdominal sites: liver (n = 4); pancreas (n = 3); peritoneum (n = 2); kidney, stomach, adrenal gland, and retroperitoneum (n = 1), respectively. Cytopathologic diagnosis was available in 5 cases. The remaining cases were considered to have myeloma deposits as a result of previous normal studies and the absence of other primary disease. The imaging findings were nonspecific. CONCLUSION Myeloma deposits within the abdomen are rare. Although the imaging findings are nonspecific, oncologists and radiologists should be aware of their common characteristics.

Use of limited MR protocol (coronal STIR) in the evaluation of patients with hip pain

ObjectiveTo assess the role of a limited MR protocol (coronal STIR) as the initial part of the MR examination in patients with hip pain.Design and patientsEighty-five patients presenting with hip pain, and normal radiographs of the pelvis, and who underwent our full MR protocol for hips were included retrospectively in the study. The full protocol consists of coronal T1-weighted and short tau inversion-recovery (STIR), and axial T2-weighted sequences. Ninety-three MR examinations were performed. Two radiologists interpreted the STIR (limited) examinations and the full studies separately, masked to each others findings and to the final diagnosis. Comparison between the two protocols was then undertaken.ResultsFor both readers, all normal MR examinations on the coronal STIR limited protocol were normal on the full protocol, with an interobserver reliability of 0.96. The STIR protocol was able to detect the presence or absence of an abnormality in 100% of cases (sensitivity). The STIR-only protocol provided a specific diagnosis in only 65% of cases (specificity).ConclusionA normal coronal STIR study of the hips in patients with hip pain and normal radiographs precludes the need for further pelvic MR sequences. Any abnormality detected on this limited protocol should be further assessed by additional MR sequences.

Bilateral breast involvement in acute myelogenous leukemia.

Sir, Breast involvement in leukemia is uncommon and the radiological findings have been described in only a few reports in the literature [1, 2, 3]. We report on a woman with acute myelogenous leukemia, (AML-M2), who, on her first presentation, had bilateral breast infiltration by leukemia, proven by fine-needle aspirate. The patient was a 51-year-old woman who presented with 2-month history of progressive weakness and dizziness associated with painful engorgement of both breasts. On physical examination the patient was very pale, and both breasts were tender, engorged, and macronodular in consistency. A complete blood cell count revealed anemia, thrombocytopenia, and a slightly elevated white blood cell count, with blasts in the peripheral smear. Bone marrow aspirate showed total replacement by myeloblasts. Flow cytometry confirmed the diagnosis of acute myelogenous leukemia (M2). Baseline bilateral mammograms showed marked and diffuse increase in the density of both breasts (Fig. 1). Ultrasound revealed thickened and coarse breast parenchyma bilaterally with distorted echotexture, in addition to a small irregular hypoechoic lesion in the left breast. Random fine needle aspirates taken from both breasts revealed immature hematopoietic cells (blasts) consistent with leukemic infiltrate. Following three cycles of chemotherapy, repeat imaging showed almost complete resolution of the abnormal findings in the breasts both on mammography and ultrasound. This was accompanied by complete clinical remission from the disease. Involvement of breasts with hematologic malignancy is uncommon. It is most often due to lymphoma, less frequently leukemia, and rarely multiple myeloma [1]. Lymphomatous and leukemic breast involvement constitutes approximately 0.25 % of all breast tumors. Breast infiltration by leukemic cells may occur either on presentation or during relapse of leukemic disease, or may also develop in women who undergo radiation therapy for breast carcinoma. All forms of leukemia have been reported to occur in the breasts. The M2 form has been described previously in two patients [3]. Breast involvement by leukemic infiltration is usually bilateral [2] but may be unilateral [3]. Clinically, patients can present with either single or multiple masses [3], or with diffuse breast enlargement with or without nodularity [2]. The affected patients are predominantly young adults. Mammographic findings in leukemia are variable and seldom reported in the literature. The mammogram can be normal [1, 3] or show one of the following: (a) enlarged breasts with diffusely coarse parenchyma [21, as seen in our patient (Fig. 1); (b) ill-defined mass with irregular borders simulating carcinoma [1, 3]; or (c) a solitary nodule simulating a benign lesion [3]. As for ultrasound, one report described the presence of multiple masses with mixed echogenicity and high vascularity on color Doppler examination. In our patient ultrasound revealed diffuse disturbed echotexture with thickened trabeculae, in addition to an irregular hypoeehoic lesion. 1031

Cyclophosphamide and Topotecan as First-line Salvage Therapy in Patients With Relapsed Ewing Sarcoma at a Single Institution

The combination of cyclophosphamide and topotecan (cyclo/topo) has shown objective responses in relapsed Ewing sarcoma, but the response duration is not well documented. We reviewed characteristics and outcome of 14 patients with Ewing sarcoma, treated uniformly at a single institution and offered cyclo/topo at first relapse. Six patients (43%) had relapse at distant sites. All patients received first-line salvage therapy with cyclophosphamide 250 mg/m2 and topotecan 0.75 mg/m2, daily for 5 days repeated every 21 days. The median number of cycles was 4 (range 1 to 10). All toxicities were manageable, the most common being transient cytopenias. There were also 4 episodes of febrile neutropenia, and 3 episodes of gross hematuria. Response was assessable in 13 patients and showed progressive disease in 6 (46%), stable disease in 4 (31%), and partial response in 3 (23%). Nine patients had local control, consisting of radical surgery in 2, radiation in 3, and a combination in 4 patients. Response, when it occurred, was maintained for a median of 8 months (range, 4 to 28 mo). Four patients (29%) are alive at 3, 7, 9, and 110 months after relapse; 1 is receiving cyclo/topo, 1 is on third-line therapy, and 2 are in second and fourth remission. The low toxicity of this combination, and the lack of sustained responses, warrant its investigation in combination with targeted or novel therapeutic agents in relapsed disease.

Abdominal complications of chemotherapy in pediatric malignancies: imaging findings ☆

OBJECTIVE To describe the imaging findings of abdominal complications caused by chemotherapy in pediatric cancer patients. SUBJECTS AND METHODS Radiology studies of 243 patients treated in our Children Cancer Center were reviewed, 164 of whom had abdominal studies. Medical records of 54 patients with abnormal imaging findings were studied. RESULTS Ultrasound and/or CT findings showed the following complications: (1) gallbladder sludge/crystals (n=13), gallstones (n=8), cholecystitis (n=3); (2) liver steatosis (n=23), siderosis (n=1), veno-occlusive disease (n=2); (3) pancreatitis (n=7); (4) typhlitis (n=12), esophagitis (n=2). CONCLUSION Awareness of these complications is essential for appropriate management, decreasing their mortality and morbidity.

Radiology of terror injuries: the American University of Beirut Medical Center experience.

OBJECTIVE This study aimed to report our experience with regard to imaging of mass casualty incidents (MCIs). SUBJECTS AND METHODS Following a bomb attack, 150 casualties were referred to our hospital. Radiographs and nonenhanced CT scans were performed in 28 individuals. RESULTS Major injuries were seen in 12 individuals, which were limited only to the brain (n=2), facial bones (n=2), and extremities and soft tissues (n=8). CONCLUSION In MCIs, imaging should be fast, in order to help identify major injuries that need immediate management and to help in the triage of injured individuals.

Practical approach to the child presenting with back pain

Back pain may be the presenting symptom of many children attending to pediatric health care settings. As such, awareness to the common etiologies of back pain in this subgroup of patients remains essential as it guides appropriate diagnosis. Although several clues may be derived from the child’s history and physical examination, imaging techniques may be required to confirm the underlying diagnosis. This review summarizes the most commonly encountered causes of back pain in children and highlights diagnostic approaches that will ensure early diagnosis and intervention for a more favorable outcome.

The impact of zoledronic acid on regenerate and native bone after consolidation and removal of the external fixator: An animal model study

We investigated the role of zoledronic acid on the regenerate and native bone after consolidation and removal of the external fixator in a rabbit model of distraction osteogenesis using 28 New Zealand white rabbits. The rabbits were randomly distributed into two groups. The first group received three doses of zoledronic acid (ZA) 0.1 mg/kg subcutaneously at weekly intervals while the second group received injections of sterile saline. Distraction started on day 7 at a rate of 0.8 mm/day for 12 days. At week 3 the average lengthening, regenerate density, and regenerate continuity were comparable between the two groups. At week 11 the regenerate in the treated group had a significant increase in Bone Mineral Density (BMD) and Bone Mineral Content (BMC) compared to the placebo group. On axial compression, the regenerate showed an increase in the peak load and a higher modulus of elasticity in the treated group. At 6 months, radiographs demonstrated signs of osteopenia of the proximal metaphysis in the control group, and failure of new bone formation around the pin sites in the treated group. BMC and BMD value differences between the two groups were not statistically significant. Histologically, there was persistence of more bone trabeculae in the medullary canal of the regenerate with the persistence of the pin-holes in the treated group. Mechanically, the regenerates in the treated group remain stronger in resisting the axial compression. The proximal fragment in the treated group exhibited a statistically significant decrease in the peak load, toughness and efail %. In conclusion, bisphosphonate-treated rabbits have a stronger regenerate during distraction, and directly after removal of the fixator. They do not develop disuse osteopenia in their lengthened tibia. This treatment may shorten the time in the external fixator and prevent fragility fractures in the treated extremity. However, its long-term safety has not yet been established.