Paolo Spinnato

Contrast enhanced MRI and 18F-FDG PET-CT in the assessment of multiple myeloma: A comparison of results in different phases of the disease

OBJECTIVES The aim of our study was to compare the accuracy of contrast enhanced MRI and FDG PET-CT in the staging, treatment evaluation and follow-up of multiple myeloma. METHODS We retrospectively reviewed 210 PET-CT and 210 MRI studies of patients affected by multiple myeloma. MRI was always performed within 15 days of PET-CT. All the images have been evaluated by two expert oncologic radiologists. RESULTS Patient population included 81 females and 110 males (age 61.9 ± 9.9 years-old). Sixty-two patients have been evaluated at diagnosis, 58 at the end of therapies and 90 during follow-up. In 12/62 patients (19.4%) at diagnosis, differences between MRI and PET-CT findings determined changes in the staging: PET-CT was responsible for 11 down-staging (17.7%) and MRI only for one (1.6%). In 27/40 patients (67.5%) with good or complete clinical response to therapies the normalization of findings was faster for PET-CT than MRI. Ten out of 90 patients (10/90 - 11.1%) in follow-up protocol presented clinical recurrence of the disease: MRI detected active lesions in 8 of them (80.0%) and PET-CT in 5 patients (50.0%, all detected by MRI too). CONCLUSIONS MRI achieved better results than PET-CT in the staging and in patients with multiple myeloma recurrence. PET-CT, showed prompt change of imaging findings, faster than MRI, in patients with positive response to therapy.

A careful evaluation of scout CT lateral radiograph may prevent unreported vertebral fractures

OBJECTIVES Our purpose was to review scout CT lateral radiographs to reveal osteoporotic vertebral fractures unreported by radiologists and to explore scout CT as a potential diagnostic tool in the detection of vertebral fractures. METHODS We considered 500 patients (303 males, 197 females, age 64.6±13.5 year-old). Our investigation was firstly focused on scout CT lateral images to detect vertebral fractures with a combined semiquantitative and quantitative diagnostic approach. Findings addressed to vertebral fracture were subsequently confirmed by multiplanar sagittal CT reconstructions. Whenever a vertebral fracture was discovered the radiologist report was read and a collection of patient anamnesis followed to understand whether fractures were already known. RESULTS In 44/500 patients (8.8%) the evaluation on scout CT was incomplete or limited for patient/technical-based conditions, and 15 were excluded from the analysis. In 67/485 patients (13.8%) 99 vertebral fractures were detected. Among 67 fractured patients only 18 (26.9%) were previously diagnosed by radiologists. However, in the clinical history of 32 patients vertebral fractures were already known. CONCLUSIONS The perception and sensibility to vertebral fractures among radiologists are still poor when the assessment of the spine is not the aim of the examination. Short time spent for the evaluation of scout CT lateral radiographs could improve our accuracy.

Dual-Energy X-Ray Absorptiometry in the Evaluation of Abdominal Aortic Calcifications

The objective of this study was to evaluate the diagnostic performance of the new dual-energy X-ray absorptiometry equipment vs digital radiography (DR) in the detection and scoring of abdominal aortic calcifications (AACs). Seventy-five patients with indication for morphometric evaluation of the spine underwent vertebral fracture assessment (VFA) and spinal DR (gold standard). The radiographic and VFA images were analyzed to detect AAC using a previously validated 24-point scale (AAC-24) and a simplified 8-point scale (AAC-8). The evaluation was conducted by 2 expert radiologists and repeated by the more experienced of the 2 after 7d to verify the results. Patients with a score of 5 or more in AAC-24 and 3 or more in AAC-8 were considered at risk for cardiovascular diseases (CVDs). The aorta was not completely visible in 11 VFA and 1 DR images. DR detected AAC in 42 of the 63 patients (66.7%), whereas 15 patients (23.8%) were considered at risk for CVD. The VFA showed sensitivity, specificity, and accuracy in the detection of AAC with values of 78.6%, 85.7%, and 81.0%, respectively, with both AAC-24 and AAC-8; in the identification of patients at risk for CVD, VFA demonstrated sensitivity, specificity, and accuracy, respectively, with values of 86.7%, 100%, and 96.8% using AAC-24 and 86.7%, 93.8%, and 92.1% using AAC-8. In the detection of AAC, intraobserver agreement was superimposable using both the techniques (κ=1.00), whereas in the identification of patients at risk for CVD, kappa values were 0.96 and 0.95 using AAC-24 and 1.00 and 0.96 using AAC-8 for DR and VFA, respectively. Interobserver agreement in the evaluation of the presence/absence of AAC showed a kappa value of 0.76 for DR and 0.71 for VFA, whereas kappa values of 0.91 and 0.87 for DR and 0.85 and 0.83 for VFA were achieved for CVD risk using AAC-24 and AAC-8, respectively. AAC can be easily and accurately diagnosed by VFA with satisfactory accuracy, reproducibility, and repeatability. VFA may be used in the assessment and monitoring of AAC.

A comprehensive review of pulsed radiofrequency in the treatment of pain associated with different spinal conditions

OBJECTIVE The objective of this review was to evaluate the efficacy of pulsed radiofrequency (PRF) treatment of pain associated with different spinal conditions. The mechanisms of action and biological effects are shortly discussed to provide the scientific basis for this radiofrequency modality. METHODS We systematically searched for clinical studies on spinal clinical conditions using PRF. We searched the MEDLINE (PubMed) database. We classified the information in one table focusing on randomized controlled trials (RCTs) and other types of studies. Date of last electronic search was October 2016. RESULTS We found four RCTs that evaluated the efficacy of PRF on cervical radicular pain and five observational studies. Two trials and three observational studies were conducted in patients with facet pain. For disc-related pathology, we found one RCT with PRF applied intradiscally and three RCTs for dorsal root ganglia PRF modulation lumbosacral radicular pain. For sacroiliac joint pain, spondylolisthesis, malignancies and other minor spinal pathology, limited studies were conducted. CONCLUSION From the available evidence, the use of PRF to the dorsal root ganglion in cervical radicular pain is compelling. With regard to its lumbosacral counterpart, the use of PRF cannot be similarly advocated in view of the absence of standardization of PRF parameters, enrolment criteria and different methods in reporting results; but, the evidence is interesting. The use of PRF in lumbar facet pain was found to be less effective than conventional RF techniques. For the other different spinal conditions, we need further studies to assess the effectiveness of PRF. Advances in knowledge: The use of PRF in lumbar facet pain was found to be less effective than conventional RF techniques. For the other different spinal conditions, we need further studies to assess the effectiveness of PRF.

Diffuse lung disease associated with neurofibromatosis type-1 can also affect children

A 4-year-old child affected by neurofibromatosis type-1 (NF1) was submitted to computed tomography (CT) of the spine for the assessment of severe scoliosis. The CT scan confirmed scoliosis and revealed multiple rows of small sub-pleural air-filled lesions at the pulmonary upper lobes (Fig. 1). These pulmonary blebs present very thin walls (< 1 mm) and small diameters (2–7 mm). These findings suggested the diagnosis of diffuse lung disease associated with NF-1 (NF-DLD). Other lung regions were normal, no basilar fibrosis was detected. NF-1 is an autosomal-dominant disease with a prevalence of one in 3000 [1]. Most common clinical manifestations include “cafè au lait” skin macules, cutaneous and central nervous system tumours. NF-DLD is described as possible manifestation of NF-1 in adult patients. The disease is generally characterized by basilar fibrosis and/or upper lobes air-filled lesions such as bullae, blebs (as in the case) or cysts [2]. Symptomatic patients usually present with dyspnoea on exertion; pulmonary function tests show either an obstructive or a restrictive defect [2]. Sub-pleural air-filled lesions represent a risk of pneumothorax which could be the first clinical manifestation of the disease [3]. This is, to our knowledge, the only pediatric patient with documented NF-DLD. This case together with a youngadult patient reported in the literature (16 years old) [3], both with upper lobes air-filled sub-pleural lesions and no basilar fibrosis, suggests that these lesions may arise before fibrotic basilar involvement, even in childhood/adolescence.

Potassium Citrate Supplementation Decreases the Biochemical Markers of Bone Loss in a Group of Osteopenic Women: The Results of a Randomized, Double-Blind, Placebo-Controlled Pilot Study

The relationship involving acid-base imbalance, mineral metabolism and bone health status has previously been reported but the efficacy of the alkalizing supplementation in targeting acid overload and preventing bone loss has not yet been fully elucidated. In this randomized, double-blind, placebo-controlled study, the hypothesis that potassium citrate (K citrate) modifies bone turnover in women with postmenopausal osteopenia was tested. Three hundred and ten women were screened; 40 women met the inclusion criteria and were randomly assigned to the treatment or the placebo group. They were treated with K citrate (30 mEq day−1) or a placebo in addition to calcium carbonate (500 mg day−1) and vitamin D (400 IU day−1). At baseline and time points of 3 and 6 months, serum indicators of renal function, electrolytes, calciotropic hormones, serum bone turnover markers (BTMs) (tartrate-resistant acid phosphatase 5b (TRACP5b), carboxy-terminal telopeptide of type I collagen (CTX), bone alkaline phosphatase (BAP), procollagen type 1 N terminal propeptide (PINP)), and urine pH, electrolytes, and citrate were measured. The follow-up was completed by 17/20 patients in the “K citrate” group and 18/20 patients in the “placebo” group. At baseline, 90% of the patients exhibited low potassium excretion in 24 h urine samples, and 85% of cases had at least one urine parameter associated with low-grade acidosis (low pH, low citrate excretion). After treatment, CTX and BAP decreased significantly in both groups, but subjects with evidence of low-grade acidosis gained significant benefits from the treatment compared to the placebo. In patients with low 24h-citrate excretion at baseline, a 30% mean decrease in BAP and CTX was observed at 6 months. A significant reduction was also evident when low citrate (BAP: −25%; CTX: −35%) and a low pH (BAP: −25%; CTX: −30%) were found in fasting-morning urine. In conclusion, our results suggested that K citrate supplementation improved the beneficial effects of calcium and vitamin D in osteopenic women with a documented potassium and citrate deficit, and a metabolic profile consistent with low-grade acidosis.

CT and 3D CT of the Elbow

Computed tomography (CT) provides important information in the evaluation of the musculoskeletal system. It represents the completion of a diagnostic path started with conventional radiography (XR). When the XR images do not allow a clear diagnosis, CT plays a fundamental role, especially with the supplement use of multi-planar and three-dimensional processing images that allow a better assessment of the regional anatomy. These techniques are used especially for districts difficult to explore with XR or those with complex anatomy such as the elbow.

Torticollis After a Somersault: A Case of Grisel’s Syndrome

A three-year-old boy attended the emergency department with acute neck pain and torticollis after a somersault. The child performed a forward somersault keeping both palms and the top of his head in touch with the ground while pushing forward to roll, causing a mechanical compressive stress to upper cervical vertebrae. Clinical examination revealed extreme neck stiffness and head fixed in maximum left rotation with some degrees of flexion (‘cockrobin’position). Conventional radiography suggested atlanto-axial joint dislocation (Fig. 1). Computed Tomography (CT) of the cervical spine with C1-C2 three-dimensional reconstruction revealed atlanto-axial rotatory subluxation (Fig. 1) without fracture. The child was at that time affected by pharyngitis and tonsillitis with cervical lymphadenopathies, conditions confirmed by Magnetic Resonance Imaging (Fig. 2). These findings oriented the diagnosis of Grisel’s syndrome. The child was successfully treated with cervical traction together with medical therapy (anti-inflammatories and antibiotics). Grisel’s syndrome consists of atlanto-axial rotatory subluxation or fixation, secondary to an inflammatory process of the adjacent tissues such as pharyngitis with retropharyngeal abscess, or local surgery (usually adenotonsillectomy), with secondary ligamentous laxity [1]. The condition occurs primarily in children after minor trauma, sharp movements or without any traumatic event [2].

MRgFUS of osteoid osteoma started at the Rizzoli

BackgroundOsteoid osteoma is a bone-producing lesion frequentlylocalized in long bones. The most common presentingsymptom is pain with nocturnal exacerbation, respon-sive to nonsteroidal anti-i nflammatory drugs [1]. Mini-mally invasive treatment options have become thestandard of care for osteoid osteoma and at presentradiofrequency ablation is the treatment of choice [2].Only one preliminary study has been performed usingmagnetic resonance guided focused ultrasound(MRgFUS) to treat osteoid osteoma showing MRgFUSto be effective for pain relief through thermal cell deathand periosteal denervation induced by cortical heatingrelative to acoustic energy absorption [3]. The purposeof this research was to evaluate the efficacy of MRgFUSin treating osteoid osteoma and to highlight potentialbenefits and limitations provided by this technology.Materials and methodsSeven patients affected by osteoid osteoma were consecu-tively recruited for MRgFUS (ExAblate 2100, InSightec,Israel on 1.5 T Signa Twin Speed MR system, GE, USA).The diagnosis of osteoid ost eoma was based on typicalclinical and imaging findings (CT and MRI) . Pain andfunction were scored before and after MRgFUS (VAS –0-10 scale), and any intra- and post-procedure complica-tion or adverse effect was recorded. Initial follow-upincluded clinical assessment at discharge, and everymonth.ResultsIn one patient the lesion c ould not be approached dueto the high body mass index (33 Kg/m

MRgHIFU treatment in pain palliation of bone metastases: initial experience from the Rizzoli Orthopaedic Institute

Background The increasing longevity of the population coupled with the progress of treatments for primary tumors is enhancing the incidence and the burden of distant metastases such as bone metastases. Bone metastases are the most common cause of cancer-related pain. Quality of life may be significantly impaired as a consequence of painful bone metastases. The treatment of secondary bone lesions will become even more important in the near future. The development of strategies to improve quality of life in patients with bone metastases is fundamental and represents a major clinical challenge. This issue is of huge impact on today health care and economy.