Paul Legmann

18F-Fluorodeoxyglucose Positron Emission Tomography for the Diagnosis of Adrenocortical Tumors: A Prospective Study in 77 Operated Patients

CONTEXT Most adrenal incidentalomas are nonfunctioning adrenocortical adenomas (ACAs). Adrenocortical carcinomas (ACCs) are rare but should be recognized at an early stage. OBJECTIVE The objective of the study was to evaluate the usefulness of (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) to predict malignancy in patients without a previous history of cancer. DESIGN This was a prospective, multicenter study from 2001 to 2006. SETTING The study was conducted at a network of seven university hospitals in Paris. PATIENTS Seventy-seven patients were included. All underwent surgery because of hypersecretory and/or growing benign lesions (n = 18), obvious ACCs (n = 21), or radiologically indeterminate lesions (n = 38). MAIN OUTCOME MEASURE The degree of (18)F-FDG PET uptake [maximum standardized uptake value (maxSUV)] was related to the pathological findings serving as a reference, and its diagnostic value was compared with that of computerized tomography (CT) scan. RESULTS Pathology eventually diagnosed 43 ACAs, 22 ACCs, and 12 nonadrenocortical lesions. Using a cutoff value above 1.45 for adrenal to liver maxSUV ratio, the sensitivity and specificity to distinguish ACAs from ACCs were, respectively, 1.00 (95% confidence interval 0.85-1.00) and 0.88 (95% confidence interval 0.75-0.96). Among the 38 indeterminate lesions at CT scan, we could analyze a subgroup of 16 adrenocortical tumors with high unenhanced density (>10 HU) and an inappropriate washout: (18)F-FDG PET correctly predicted the benignity in 13 of 15 ACAs. CONCLUSIONS In a multidisciplinary team approach, (18)F-FDG PET helps to manage suspicious CT scan lesions. An adrenal to liver maxSUV ratio less than 1.45 is highly predictive of a benign lesion.

Detection of myocardial involvement in patients with sarcoidosis applying T2-weighted, contrast-enhanced, and cine magnetic resonance imaging: initial results of a prospective study.

Purpose To assess myocardial magnetic resonance imaging (MRI) findings in sarcoidosis. Methods Cardiac assessment was prospectively performed in patients with sarcoidosis and included physical examination, electrocardiogram, echocardiography, thallium-201 myocardial scintigraphy, and coronary angiography if coronary disease was suspected. T2-weighted black-blood single-shot and inversion recovery fast spin echo, functional gradient echo, and T1-weighted gadolinium-DTPA-enhanced cardiac MRI examinations were performed in 40 patients while other cardiac disease was excluded. Results Results of the MRI images were normal in cardiac-asymptomatic stage I or Lofgren syndrome patients (n = 4). Among the patients with cardiac-asymptomatic multiple organ sarcoidosis, 17 of 31 patients (54%) had MRI myocardial abnormalities similar to those observed in five patients with cardiac symptoms: nodular peripheral increased intramyocardial signal intensity on both T2-weighted and contrast-enhanced images (n = 5), focal or patchy increased signal on contrast-enhanced images with or without myocardial thickening (n = 10), and focal increased signal only on T2-weighted images with or without myocardial thinning (n = 2). Focal contractility abnormalities were noticed in nine patients. Conclusions These preliminary results emphasize the occurrence of subclinical myocardial MRI abnormalities in patients with ongoing systemic sarcoidosis.

Efficiency and Tolerance of mitotane in Cushing's Disease in 76 patients from a single center

CONTEXT Alternatives to transsphenoidal pituitary surgery may be required in Cushings disease (CD) as a first- or second-line treatment. Mitotane is a potent anti-cortisolic drug but has been rarely investigated in the treatment of CD. OBJECTIVE Evaluation of the efficacy and tolerance of mitotane in CD patients. DESIGN AND SETTING Retrospective analysis of 76 patients treated with mitotane from 219 patients diagnosed with CD between 1993 and 2009 in a single center. MAIN OUTCOME MEASURE Remission was defined as normalization of 24-h urinary free cortisol (24-h-UFC). RESULTS Remission was achieved in 48 (72%) of the 67 long-term treated patients, after a median time of 6.7 (5.2-8.2) months. Mean plasma mitotane concentration at the time of remission was 10.5 ± 8.9 mg/l, with a mean daily dose of 2.6 ± 1.1 g. A negative linear relationship was observed between plasma mitotane concentration and 24-h-UFC (P<0.0001). Seventeen of 24 (71%) patients with durable remission subsequently experienced recurrence, after a median time of 13.2 (5.0-67.9) months. At the time of treatment discontinuation, ACTH concentration was statistically associated with a lower recurrence probability (hazard ratios 0.57 (0.32-1.00), P=0.05). Intolerance leading to treatment discontinuation occurred in 19 patients (29%). A pituitary adenoma became identifiable during mitotane treatment in 12 (25%) of the 48 patients with initial negative pituitary imaging allowing subsequent transsphenoidal surgery. CONCLUSION Mitotane is useful at different stages of CD. Mitotane dose adjustment based on plasma concentration monitoring and side effects could control hypercortisolism in the majority of CD patients.

Effects of corticosteroids and immunosuppressors on idiopathic inflammatory myopathy related myocarditis evaluated by magnetic resonance imaging

Background: Cardiac involvement in idiopathic inflammatory myopathy has been recognised as an important prognostic factor, but treatment remains empirical. Objective: To investigate the effects of corticosteroids and immunosuppressors on myocarditis in patients with inflammatory myopathies. Methods: Patients with inflammatory myositis of recent onset who had not received treatment were evaluated for associated myocarditis by magnetic resonance imaging (MRI) and reinvestigated after treatment with high dose corticosteroids and immunosuppressors. Results: Four patients with histologically proven myositis were included. Two patients with polymyositis had cardiac clinical symptoms. Two other patients with dermatomyositis and diffuse cutaneous systemic sclerosis-polymyositis overlap syndrome were asymptomatic. In three cases the usual conventional screening tests were normal. For all patients an area of contrast enhancement and hypokinesia detected by cardiac MRI was markedly reduced after treatment with corticosteroids and immunosuppressors for 6 months. Conclusion: Treatment with intravenous methylprednisolone followed by prednisone and immunosuppressive therapy seems to be effective for treating myocardial involvement in patients with idiopathic inflammatory myopathies, either alone or presenting as overlap syndromes. Cardiovascular MRI is a non-invasive technique that may be a powerful tool for diagnosis and monitoring of myocardial inflammation in this setting.

Spontaneous Unilateral Adrenal Hemorrhage: Computerized Tomography and Magnetic Resonance Imaging Findings in 8 Cases

PURPOSE We report and discuss the imaging features of 8 cases of spontaneous unilateral adrenal hematomas, a rare lesion. MATERIALS AND METHODS Computerized tomography (CT) was done in 8 cases, magnetic resonance imaging (MRI) in 5, and CT and MRI in 5. Imaging findings were reviewed and correlated with histological findings in all 8 cases. RESULTS MRI was the most accurate imaging modality and showed variable appearances. On pathological evaluation the hematomas were old and organized. No contrast enhancement was noted on CT or MRI. CONCLUSIONS One must not consider the diagnosis of spontaneous adrenal hematoma only as superimposed on a phechromocytoma or malignant lesion in the case of an incidentally discovered large adrenal mass with normal biological findings. MRI signs of adrenal hemorrhage and the failure of enhancement of such a mass should strongly suggest adrenal hematoma.

The Nelson's syndrome... revisited

Adrenalectomy is a radical therapeutic approach to control hypercortisolism in some patients with Cushings disease. However it may be complicated by the Nelsons syndrome, defined by the association of a pituitary macroadenoma and high ACTH secretion after adrenalectomy. This definition has not changed since the end of the fifties. Today the Nelsons syndrome must be revisited with new to criteria using more sensitive diagnostic tools, especially the pituitary magnetic resonance imaging.In this paper we will review the pathophysiological aspects of corticotroph tumor growth, with reference to the impact of adrenalectomy. The main epidemiological data on the Nelsons syndrome will be presented.More importantly, we will propose a new pathophysiological and practical approach to this question which attempts to evaluate the Corticotroph Tumor Progression after adrenalectomy, rather than to diagnose the Nelsons syndrome. We will discuss the consequences for the management of Cushings disease patients after adrenalectomy, and will also draw some perspectives.

Magnetic Resonance Imaging and Endometriosis: Deeply Infiltrating Endometriosis Does Not Originate from the Rectovaginal Septum

The goal of this study was to describe the magnetic resonance (MR) imaging signs of deeply infiltrating endometriosis (DIE) lesions and above all to find out if MR imaging can pinpoint the location of these lesions. We made a retrospective study of 8 patients presenting with histologically proven DIE lesions. The MR imaging results were compared with intraoperative findings. Nodules revealed on T1-weighted images as isointense to myometrium with hyperintense spots remained visible on the fat-suppressed spin echo images. When there was no rectal involvement, the T1- and T2-weighted images showed a hypointense transition area between the nodule and the rectum. The DIE nodules were in identical locations in every case, lying below the torus uterinum, level with the posterior vaginal fornix and the upper third of the posterior vaginal wall. Without exception, the DIE nodules were located above the upper edge of the rectovaginal septum, with the latter appearing fine and regular with no image of any nodule. Our MR imaging results suggest that DIE lesions do not originate from the rectovaginal septum.

Tumor target volume for focal therapy of prostate cancer-does multiparametric magnetic resonance imaging allow for a reliable estimation?

PURPOSE We determined whether endorectal multiparametric magnetic resonance imaging at 1.5 Tesla could predict tumor target volume in the perspective of focal therapy of prostate cancer. MATERIALS AND METHODS A total of 84 consecutive patients underwent multiparametric magnetic resonance imaging before radical prostatectomy. The volume of each suspicious area detected on magnetic resonance imaging and of all surgical histological foci was determined by planimetry. We first used each magnetic resonance imaging sequence (T2-weighted, diffusion weighted and dynamic contrast enhanced) and then the sequence showing the largest tumor area (multiparametric volume). Finally, the largest area of any sequence was used to calculate a target volume according to the volume of a cylinder. Agreement between magnetic resonance imaging and pathological findings was assessed by linear regression and residual analysis. RESULTS Histology revealed 99 significant tumors with a volume of greater than 0.2 cc and/or a Gleason score of greater than 6. Of the tumors 16 (16.2%) were undetected by multiparametric magnetic resonance imaging. Linear regression analysis showed that tumor volume estimated by T2-weighted or diffusion weighted imaging correlated significantly with pathological volume (r(2) = 0.82 and 0.83, respectively). Residuals from diffusion weighted imaging volume estimations did not significantly differ from 0. Nevertheless, diffusion weighted imaging underestimated pathological volume in 43 of 87 cases (49%) by a mean of 0.56 cc (range 0.005 to 2.84). Multiparametric and target volumes significantly overestimated pathological volume by a mean of 16% and 44% with underestimation in 28 (32%) and 15 cases (17%), respectively. Volume underestimation was significantly higher for tumor foci less than 0.5 cc. The percent of Gleason grade 4 did not influence tumor volume estimation. CONCLUSIONS Magnetic resonance imaging can detect most significant tumors. However, delineating a target volume may require further adjustment before planning magnetic resonance imaging targeted focal treatment.

Cyclic sciatica. A manifestation of compression of the sciatic nerve by endometriosis. A case report.

Study design A case of cyclic sciatica secondary to ovarian cyst endometriosis is presented. Objectives To report the clinical description and magnetic resonance imaging aspects of cyclic sciatica. Summary of Background Data Endometriosis of the sciatic nerve is rare, but must be included in the differential diagnosis of sciatic mononeuropathies. Methods The authors report a new case of a woman whose cyclic sciatica was caused by an ovarian cystic endometriosis lesion. Results Magnetic resonance imaging was described as hyper‐ and hypointense on T1‐weighted sequences, and hyperintense on T2‐weighted sequences at the sciatic notch. Conclusion Magnetic resonance imaging may permit a specific diagnosis of this unusual cause of sciatica by showing a hemorrhagic mass in the region of the sciatic nerve. Early recognition is necessary to prevent permanent damage to the sciatic nerve.

Hemorrhagic necrosis due to peliosis hepatis: imaging findings and pathological correlation.

Abstract. Peliosis hepatis is an uncommon liver condition characterized by blood-filled cavities. We report the CT, angiographic and MR features of a case of peliosis hepatis with no obvious etiology and spontaneously regressing hemorrhagic necrosis. Helical CT showed multiple peripheral low-density regions with foci of spontaneous high density suggesting the presence of blood component. On MR imaging, the multiple peripheral lesions were hypointense on T1-weighted and hyperdense on T2-weighted images, with bright foci on all sequences suggesting subacute blood. Angiography showed no evidence of tumor or vascular malformation; multiple nodular vascular lesions filling in the parenchymal phase and persisting in the venous phase suggested blood-filled cavities. Pathological examination showed blood-filled spaces with no endothelial lining, characteristic of the parenchymal type of peliosis. Knowledge of the imaging features of hemorrhagic necrosis due to peliosis hepatis is important since it can be responsive to antibiotic therapy. Furthermore, differentiating hemorrhagic necrosis from hepatic abscess avoids dangerous and sometimes fatal percutaneous drainage.