William M. Kauffman

Accuracy of MR imaging for detecting epiphyseal extension of osteosarcoma

Background. Too few patients are receiving epiphyseal-sparing limb salvage procedures for osteosarcoma. Objective. To determine how magnetic resonance (MR) imaging can best predict the epiphyseal extension of osteosarcoma. Materials and methods. Forty children underwent complete pretreatment static and dynamic contrast-enhanced MR imaging (DEMRI). Static MR images [T1-weighted and short tau inversion recovery (STIR)] of the epiphyses were read in three ways: (1) for suspicion of any abnormality (tumor or edema), (2) for suspicion of tumor, excluding suspected edema, and (3) validating the second method by using a scale to rate the likelihood of tumor. Presentation imaging was compared to histopathologic findings after chemotherapy and resection. The receiver operating characteristic (ROC) method was used to analyze the scaled ratings of static MR and DEMRI values. Results. At delayed resection, 20 of 40 children with osteosarcoma had confirmed epiphyseal tumor; however, 32 epiphyses were abnormal on STIR and 28 abnormal on T1. Differentiating suspected tumor from edema increased the accuracy to an Az (area under the ROC curve) of 0.94 for both T1-weighted and STIR static sequences. T1-weighted MR had better specificity and STIR better sensitivity at any given rating. DEMRI was slightly less accurate (Az = 0.90). Conclusion. Static MR imaging most accurately detected epiphyseal extension of osteosarcoma when readers distinguished suspected tumor from edematous or normal tissue.

Hepatic veno-occlusive disease in children undergoing bone-marrow transplantation: usefulness of sonographic findings.

Background. Reports of the usefulness of ultrasonography in the diagnosis of hepatic veno-occlusive disease (HVOD) have presented conflicting results.¶Objective. To determine the usefulness of gray-scale or Doppler ultrasonographic measurements in the diagnosis of HVOD in pediatric patients undergoing BMT.¶Materials and methods. We prospectively obtained 202 serial sonograms on 48 patients and examined the association between the clinical diagnosis of HVOD (McDonald criteria) and eight ultrasound parameters, including the hepatic artery resistive index (HARI), direction and velocity of portal venous flow, and thickness of the gall bladder wall.¶Results. HVOD developed in 29 of the 48 patients. The portal venous velocity increased after BMT in the group without HVOD and decreased in the group with HVOD; this difference was significant (P = 0.01). However, there was a great deal of variability in velocity measurements for individual patients. The mean HARI was 0.64 in the group with HVOD and 0.63 in the group without HVOD, and there was no difference between the two groups in the pattern of change in HARI relative to the day of BMT (P = 0.4). There was also no significant difference in thickness of the gallbladder wall between the two groups (P = 0.6).¶Conclusion. No ultrasound parameter studied was as useful as the McDonald criteria for diagnosing HVOD.

MR imaging findings in recurrent primary osseous Ewing sarcoma

The objective of this study was to determine the value of magnetic resonance (MR) imaging in diagnosing local recurrence of Ewing sarcoma. We retrospectively reviewed radiographs, Tc99m-methylene diphosphonate (MDP) skeletal scintigraphy, computed tomography scans, and MR studies of 11 patients who had local recurrences of osseous Ewing sarcoma following initial responses to chemotherapy and local radiation. The MR images were compared to those of a control group of nine patients who had no evidence of relapse. T1- and T2-weighted MR images identified 9 of the 11 recurrences. Computed tomography was diagnostic in 4 of 6 cases evaluated, Tc99m-MDP bone scintigraphy in 4 of 11 cases, and plain radiographs in 2 of 10. MR findings at relapse included changes in signal intensity, increased extent of abnormal marrow signal on T1- and T2-weighted images, and identification of a new soft tissue mass. These findings suggest that MR imaging is valuable in the routine follow-up of primary osseous Ewing sarcoma.

Detection of Adrenal Metastasis From Osteosarcoma by Tc-99m Mdp Scintigraphy

A 16-year-old boy had osteosarcoma of the distal left femur diagnosed at age 10. At presentation there was no evidence of bony or pulmonary metastases. Five years later, the right ring finger was amputated because of bony recurrence at that site, and soon after the patient underwent bilateral thoracotomies for resection of pulmonary metastases. Follow-up evaluation with Tc-99m MDP skeletal scintigraphy demonstrated a large region of increased uptake in the left upper quadrant of the abdomen. Noncontrast axial CT revealed a large calcified soft tissue mass in the left suprarenal region consistent with adrenal metastasis from osteosarcoma.

Imaging features of ovarian metastases from colonic adenocarcinoma in adolescents

This paper describes the imaging features of ovarian metastases from adenocarcinoma of the colon in adolescent females. We reviewed retrospectively abdominal and pelvic computed tomographic and pelvic ultrasound examinations, histologic slices, and clinical charts of six adolescent females with ovarian metastases secondary to adenocarcinoma of the colon. One patient had ovarian metastasis at presentation and was presumed to have a primary ovarian tumor. The ovarian metastases were either solid (n=3), complex with both solid and cystic components (n=2), or multilocular cysts (n=1). The ovarian lesions were large, ranging from 6 cm to 18 cm in diameter. Colorectal carcinoma in adolescent females is frequently associated with ovarian metastases. One imaging characteristic differs in adult and adolescent ovarian metastases, although they do have features in common: in adolescents, a smaller proportion of colorectal ovarian metastases are multicystic (17%) compared with the adult series (45%). These lesions are frequently large and may be complex, multicystic, or solid. Although it is a rare disease, the differential dignosis of adnexal masses in adolescent females should include ovarian metastases from adenocarcinoma of the colon.

Magnetic resonance imaging for evaluation of childhood aplastic anemia.

Purpose We prospectively evaluated the ability of magnetic resonance imaging (MRI) of the thoraco-lumbar vertebrae to determine the relative amount of red and fatty marrow in children with aplastic anemia. Patients and Methods Twenty pediatric patients (ages 1–19 years) with aplastic anemia underwent T1-weighted (T1W, n = 31) and short T1 inversion recovery (STIR, n = 30) MRI of the midline sagittal thoraco-lumbar spine. Bone marrow (BM) biopsies from the posterior iliac crest (n = 29) were also performed. All studies were evaluated by blinded observers; MR grading was based on visual inspection of signal intensity. Biopsy-estimated cellularity was compared with T1W and STIR grading when these were performed within 14 days of each other (n = 16). All studies were compared to a simultaneous absolute neutrophil count (ANC), absolute reticulocyte count (ARC), and platelet count. Results BM cellularity estimated by BM biopsy was significantly associated with STIR grading (p = 0.032, Jonckheere-Terpstra test), as were peripheral ANC (p = 0.044), ARC (p = 0.007), and platelet count (p = 0.003). T1W grade was significantly associated with ANC (P = 0.011) but not ARC (p = 0.053) or platelet count (p = 0.377). Biopsy-estimated cellularity was associated with ANC (p = 0.032) and ARC (p = 0.036), but not platelet count (p = 0.282). Conclusion In childhood aplastic anemia patients, STIR (and, to a lesser extent, T1W) MRI of the thoraco-lumbar spine reflects BM activity, as measured by peripheral blood ANC, ARC, and platelet count, and BM cellularity, as measured by BM biopsy. MRI may thus provide a noninvasive measure of hematopoietic status.

Chest radiographic features of thoracic metastatic disease in adolescents with colon cancer

This study describes chest radiographic features of thoracic metastatic disease (TMD) in patients referred for colon cancer to a pediatric oncology hospital. The study group was comprised of 9 patients (7 males, 2 females, age 13–19 years) with serial chest radiographs demonstrating TMD from colon cancer. All patients had a chest radiograph performed within the 2 months prior to death. The median interval from diagnosis of colon cancer to appearance of radiographic TMD was 3 months. Four of nine patients had TMD at presentation, eight of nine patients within 2 years of diagnosis. All abnormalities progressed on serial radiographs. The median interval from appearance of radiographic abnormalities to death was 2 months. Radiographic findings included pleural effusions (n=6), lymphadenopathy (n=5), lymphangitic carcinomatosis (n=4), solitary pulmonary nodule (n=2), and lobar atelectasis (n=1). Five patients with pleural effusions initially had right-sided effusions. Radiographic TMD in adolescents with colon cancer usually occurs within 2 years of diagnosis. Once TMD manifests, the prognosis is dismal. Findings include pleural effusions, lymphadenopathy, lymphangitic carcinomatosis, solitary pulmonary nodules, and lobar atelectasis. We suggest that metastatic colon carcinoma should be included in the differential diagnosis for lymphangitic spread of tumor in adolescents.

Childhood lymphoma: Diagnostic accuracy of chest radiography for severe pulmonary complications

INTRODUCTION We sought to determine whether chest radiography can be reliably used to distinguish persistent or relapsing pulmonary lymphoma from a variety of infectious and noninfectious pulmonary conditions that can occur in children receiving treatment for lymphoma. METHODS We studied chest radiographs of 37 patients (30 with non-Hodgkins lymphoma, and seven with Hodgkins disease) who died of paediatric lymphoma or of treatment complications. Pulmonary findings at autopsy comprised lung tumour (n = 14), pleural tumour (n = 12), pneumonia (n = 22), adult respiratory distress syndrome (ARDS; n = 16), haemorrhage (n = 27), and infarction (n = 13). Using a 4-point scale and without knowledge of autopsy findings, three radiologists independently rated antemortem radiographs for the presence of pulmonary tumour, pleural tumour, pneumonia in general, pneumonia caused by viral, bacterial, fungal, and protozoan pathogens, ARDS, pulmonary haemorrhage, and pulmonary infarction. Diagnostic accuracy was defined by the area under the receiver-operating-characteristic curve (AZ). RESULTS Diagnostic accuracy was good for pulmonary tumour (AZ, 0.71 +/- 0.6), protozoan pneumonia (AZ, 0.77 +/- 0.06), and ARDS (AZ, 0.86 +/- 0.07) but poor for all other conditions. The absence of both pleural effusions and mediastinal/right hilar lymphadenopathy was significantly associated (P < or = 0.04) with the absence of lung tumour. DISCUSSION The pulmonary processes in these patients can all demonstrate diffuse airspace opacification, and many patients had multiple lung abnormalities at autopsy. The radiologist-readers were unable to identify which pulmonary conditions were responsible for radiographic findings in most patients. The readers were able to identify patients who did not have pulmonary lymphoma. If pulmonary involvement with lymphoma is unlikely, bronchoscopy with bronchoalveolar lavage may be sufficient to establish a diagnosis. When pulmonary lymphoma is a clinical consideration, open lung biopsy is usually required for diagnosis.