Anatomic Subtype Differences in Extramammary Paget Disease: A Meta-Analysis

Importance

Extramammary Paget disease (EMPD) is a rare, highly recurrent cutaneous malignant neoplasm of unclear origin. EMPD arises most commonly on the vulvar and penoscrotal skin. It is not presently known how anatomic subtype of EMPD affects disease presentation and management.

Objective

To compare demographic and tumor characteristics and treatment approaches for different EMPD subtypes. Recommendations for diagnosis and treatment are presented.

Data Sources

MEDLINE, Embase, Web of Science Core Collection, and Cochrane Reviews CENTRAL from December 1, 1990, to October 24, 2022.

Study Selection

Articles were excluded if they were not in English, reported fewer than 3 patients, did not specify information by anatomic subtype, or contained no case-level data. Metastatic cases on presentation were also excluded.

Data Extraction and Synthesis

Abstracts of 1295 eligible articles were independently reviewed by 5 coauthors, and 135 articles retained. Reporting was in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The analysis was cunducted in August 2019 and updated in November 2022.

Findings

Most vulvar EMPD cases were asymptomatic, and diagnosis was relatively delayed (mean, 25.1 months). Although most vulvar EMPD cases were intraepidermal (1247/1773 [70.3%]), radical surgeries were still performed in almost one-third of cases. Despite this aggressive surgical approach, 481 of 1423 (34%) recurred, commonly confined to the skin and mucosa (177/198 [89.4%]). By contrast, 152 of 1101 penoscrotal EMPD cases (14%) recurred, but more than one-third of these recurrences were regional or associated with distant metastases (54 of 152 [35.5%]). Perianal EMPD cases recurred in one-third of cases (74/218 [33.9%]), with one-third of these recurrences being regional or associated with distant metastasis (20 of 74 [27.0%]). Perianal EMPD also had the highest rate of invasive disease (50% of cases).

Conclusions and Relevance

The diagnosis and treatment of EMPD should differ based on anatomic subtypes. Considerations for updated practice may include less morbid treatments for vulvar EMPD, which is primarily epidermal, and close surveillance for local recurrence in vulvar EMPD and metastatic recurrence in perianal EMPD. Recurrences in penoscrotal subtype were less common, and selective surveillance in this subtype may be considered. Limitations of this study include the lack of replication cohorts and the exclusion of studies that did not stratify outcomes by anatomic subtype.

Clinical Correlates of the PET-based Braak Staging Framework in Alzheimer's Disease

In vivo Alzheimer's disease diagnosis and staging is traditionally based on clinical features. However, the agreement between clinical and pathological Alzheimer's disease diagnosis, whose diagnosis assessment includes amyloid and Braak histopathological tau staging, is not completely convergent. The development of positron emission tomography (PET) tracers targeting neurofibrillary tangles offers prospects for advancing the staging of Alzheimer's disease from both biological and clinical perspectives. Recent advances in radiochemistry made it possible to apply the postmortem Braak staging framework to tau-PET images obtained in vivo. Here, our aim is to provide a narrative review of the current literature on the relationship between Alzheimer's disease clinical features and the PET-based Braak staging framework. Overall, the available studies support the stepwise increase in disease severity following the advance of PET-based Braak stages, with later stages being associated with worse cognitive and clinical symptoms. In line with this, there is a trend for unimpaired cognition, mild cognitive impairment, and Alzheimer's disease dementia to be compatible with early, intermediate, and late patterns of tau deposition based on PET-based Braak stages. Moreover, neuropsychiatric symptom severity seems to be linked to the extent of tau-PET signal across Braak areas. In sum, this framework seems to correspond well with the clinical progression of Alzheimer's disease, which is an indication of its potential utility in research and clinical practice, especially for detecting preclinical tau levels in individuals without symptoms. However, further research is needed to improve the generalizability of these findings and to better understand the applications of this staging framework.

Yield of Postmortem Skeletal Surveys in Infants Presenting to Emergency Care With Sudden and Unexpected Death

OBJECTIVES

Child abuse should be considered in cases of sudden unexpected infant death (SUID). Postmortem skeletal surveys (PM-SS) are recommended to evaluate for abusive fractures in SUID. Little is known about the yield of PM-SS among infants presenting to emergency care with SUID. Our objectives were to (1) describe the presentation and care of infants with SUID at a tertiary children's hospital emergency department and (2) report PM-SS use and findings.

METHODS

We performed a retrospective study of infants younger than 12 months with SUID presenting to an urban emergency department from 2007 to 2019. We describe their presentation and care, including PM-SS performance and findings, referrals to the medical examiner, and reports to child protective services (CPS). We assessed for associations between race, payer, and presentation with reports to CPS.

RESULTS

Of 73 infants with SUID, concern for unsafe sleep was documented in 45 (61.6%) and 71 (97.3%) underwent cardiopulmonary resuscitation by a medical professional. All 73 (100%) underwent PM-SS and were referred to the medical examiner. Twelve definite fractures (11 rib, 1 classic metaphyseal lesion) and 8 possible fractures (7 rib, 1 classic metaphyseal lesion) were identified among 6 (8.2%) infants. Forty-three (58.9%) were reported to CPS. There were no associations between race, payer, age, or history of unsafe sleep and CPS reports.

CONCLUSIONS

One in 12 cases of SUID had a possible and/or definite fracture identified on plain radiography. Multicenter studies are needed to compare yield across different postmortem imaging modalities and populations.

Imaging of pediatric renal tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper focused on Wilms tumor and nephrogenic rests

Malignant renal tumors account for approximately 6% of pediatric malignancies, with Wilms tumor (WT) representing approximately 90% of pediatric renal tumors. This paper provides consensus-based imaging guidelines for the initial evaluation of a child with suspected WT and follow-up during and after therapy co-developed by the Children's Oncology Group (COG) Diagnostic Imaging and Society for Pediatric Radiology (SPR) oncology committees. The guidelines for Wilms Tumor Imaging in the Society of International Pediatric Oncology (SIOP) are briefly discussed to highlight some of the differences in imaging approach.

Imaging of pediatric abdominal soft tissue tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper

This paper provides imaging recommendations for pediatric abdominal tumors that arise outside of the solid viscera. These tumors are rare in children and have been categorized in two groups: abdominal wall and peritoneal tumors (desmoid tumor and desmoplastic small round cell tumor) and tumors that arise from the gastrointestinal tract (gastrointestinal stromal tumor and gastrointestinal neuroendocrine tumor). Authors offer consensus recommendations for imaging assessment of these tumors at diagnosis, during follow-up, and when off-therapy.

Imaging of pediatric neuroblastoma: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper

Neuroblastoma is the most common extracranial solid neoplasm in children. This manuscript provides consensus-based imaging recommendations for pediatric neuroblastoma patients at diagnosis and during follow-up.

KIR/KIR-ligand genotypes and clinical outcomes following chemoimmunotherapy in patients with relapsed or refractory neuroblastoma: a report from the Children's Oncology Group

BACKGROUND

In the Children's Oncology Group ANBL1221 phase 2 trial for patients with first relapse/first declaration of refractory high-risk neuroblastoma, irinotecan and temozolomide (I/T) combined with either temsirolimus (TEMS) or immunotherapy (the anti-GD2 antibody dinutuximab (DIN) and granulocyte macrophage colony stimulating factory (GM-CSF)) was administered. The response rate among patients treated with I/T/DIN/GM-CSF in the initial cohort (n=17) was 53%; additional patients were enrolled to permit further evaluation of this chemoimmunotherapy regimen. Potential associations between immune-related biomarkers and clinical outcomes including response and survival were evaluated.

METHODS

Patients were evaluated for specific immunogenotypes that influence natural killer (NK) cell activity, including killer immunoglobulin-like receptors (KIRs) and their ligands, Fc gamma receptors, and NCR3. Total white cells and leucocyte subsets were assessed via complete blood counts, and flow cytometry of peripheral blood mononuclear cells was performed to assess the potential association between immune cell subpopulations and surface marker expression and clinical outcomes. Appropriate statistical tests of association were performed. The Bonferroni correction for multiple comparisons was performed where indicated.

RESULTS

Of the immunogenotypes assessed, the presence or absence of certain KIR and their ligands was associated with clinical outcomes in patients treated with chemoimmunotherapy rather than I/T/TEMS. While median values of CD161, CD56, and KIR differed in responders and non-responders, statistical significance was not maintained in logistic regression models. White cell and neutrophil counts were associated with differences in survival outcomes, however, increases in risk of event in patients assigned to chemoimmunotherapy were not clinically significant.

CONCLUSIONS

These findings are consistent with those of prior studies showing that KIR/KIR-ligand genotypes are associated with clinical outcomes following anti-GD2 immunotherapy in children with neuroblastoma. The current study confirms the importance of KIR/KIR-ligand genotype in the context of I/T/DIN/GM-CSF chemoimmunotherapy administered to patients with relapsed or refractory disease in a clinical trial. These results are important because this regimen is now widely used for treatment of patients at time of first relapse/first declaration of refractory disease. Efforts to assess the role of NK cells and genes that influence their function in response to immunotherapy are ongoing.

TRIAL REGISTRATION NUMBER

NCT01767194.

Evidence-Based Clinical Practice Guidelines for Extramammary Paget Disease

IMPORTANCE

Extramammary Paget disease (EMPD) is a frequently recurring malignant neoplasm with metastatic potential that presents in older adults on the genital, perianal, and axillary skin. Extramammary Paget disease can precede or occur along with internal malignant neoplasms.

OBJECTIVE

To develop recommendations for the care of adults with EMPD.

EVIDENCE REVIEW

A systematic review of the literature on EMPD from January 1990 to September 18, 2019, was conducted using MEDLINE, Embase, Web of Science Core Collection, and Cochrane Libraries. Analysis included 483 studies. A multidisciplinary expert panel evaluation of the findings led to the development of clinical care recommendations for EMPD.

FINDINGS

The key findings were as follows: (1) Multiple skin biopsies, including those of any nodular areas, are critical for diagnosis. (2) Malignant neoplasm screening appropriate for age and anatomical site should be performed at baseline to distinguish between primary and secondary EMPD. (3) Routine use of sentinel lymph node biopsy or lymph node dissection is not recommended. (4) For intraepidermal EMPD, surgical and nonsurgical treatments may be used depending on patient and tumor characteristics, although cure rates may be superior with surgical approaches. For invasive EMPD, surgical resection with curative intent is preferred. (5) Patients with unresectable intraepidermal EMPD or patients who are medically unable to undergo surgery may receive nonsurgical treatments, including radiotherapy, imiquimod, photodynamic therapy, carbon dioxide laser therapy, or other modalities. (6) Distant metastatic disease may be treated with chemotherapy or individualized targeted approaches. (7) Close follow-up to monitor for recurrence is recommended for at least the first 5 years.

CONCLUSIONS AND RELEVANCE

Clinical practice guidelines for EMPD provide guidance regarding recommended diagnostic approaches, differentiation between invasive and noninvasive disease, and use of surgical vs nonsurgical treatments. Prospective registries may further improve our understanding of the natural history of the disease in primary vs secondary EMPD, clarify features of high-risk tumors, and identify superior management approaches.

Pilot study for comparative assessment of dual-energy computed tomography and single-photon emission computed tomography V/Q scanning for lung perfusion evaluation in infants

OBJECTIVE

To evaluate clinical applications of dual-energy computed tomography (DECT) in pediatric-specific lung diseases and compare ventilation and perfusion findings with those from single-photon emission computed tomography (SPECT-CT) V/Q.

METHODS

All patients at our institution who underwent exams using both techniques within a 3-month period were included in this study. Two readers independently described findings for DECT, and two other readers independently analyzed the SPECT-CT V/Q scan data. All findings were compared between readers and disagreements were reassessed and resolved by consensus. Inter-modality agreements are described throughout this study.

RESULTS

Eight patients were included for evaluation. The median age for DECT scanning was 3.5 months (IQR = 2). Five of these patients were scanned for both DECT and SPECT-CT V/Q studies the same day, and three had a time gap of 7, 65, and 94 days between studies. The most common indications were chronic lung disease (5/8; 63%) and pulmonary hypertension (6/8; 75%). DECT and SPECT-CT V/Q identified perfusion abnormalities in concordant lobes in most patients (7/8; 88%). In one case, atelectasis limited DECT perfusion assessment. Three patients ultimately underwent lobectomy with corresponding perfusion abnormalities identified by all reviewers on both DECT and SPECT-CT V/Q in all resected lobes.

CONCLUSION

DECT is a feasible technique that could be considered as an alternative for SPECT-CT V/Q for lung perfusion evaluation in infants.

Evaluation of the abdomen in the setting of suspected child abuse

Abusive intra-abdominal injuries are less common than other types of injuries, such as fractures and bruises, identified in victims of child physical abuse, but they can be deadly. No single abdominal injury is pathognomonic for abuse, but some types and constellations of intra-abdominal injuries are seen more frequently in abused children. Identification of intra-abdominal injuries can be important clinically or forensically. Injuries that do not significantly change clinical management can still elevate a clinician's level of concern for abuse and thereby influence subsequent decisions affecting child protection efforts. Abusive intra-abdominal injuries can be clinically occult, necessitating screening laboratory evaluations to inform decisions regarding imaging. Once detected, consideration of developmental abilities of the child, type and constellation of injuries, and the forces involved in any provided mechanism of trauma are necessary to inform assessments of plausibility of injury mechanisms and level of concern for abuse. Here we describe the clinical, laboratory and imaging evaluation of the abdomen in the setting of suspected child abuse.

Rachitic change and vitamin D status in young children with fractures

OBJECTIVE

To examine the association between rachitic changes and vitamin D levels in children less than 2 years old with fractures.

METHODS

Children less than 2 years old who were admitted to a large children's hospital for a fracture and underwent a skeletal survey were included. Two pediatric radiologists blinded to the children's vitamin D levels independently reviewed the skeletal surveys for the following rachitic findings: demineralization, widened sutures, rachitic rosary, Looser zones, and metaphyseal changes. Kappa coefficients were calculated to assess inter-rater agreement. Logistic regression was used to test the association between vitamin D level and rachitic findings.

RESULTS

There were 79 subjects (40 female and 39 male) with a median age of 4 months. Vitamin D levels ranged from 11.6 to 88.9 ng/ml and were low in 27. Questionable demineralization was noted in seven subjects; mild to moderate demineralization was observed in four subjects. Widened sutures were noted in seven subjects, many also with concurrent intracranial hemorrhage. Lower vitamin D levels were associated with increased odds of demineralization after adjusting for age, gender, and prematurity (P < 0.015). An association was not found between the vitamin D level and suture widening (P = 0.07). None of the cases demonstrated Looser zones, rachitic rosary, or metaphyseal changes of rickets.

CONCLUSIONS

Infants and toddlers with fractures frequently have suboptimal vitamin D levels, but radiographic evidence of rickets is uncommon in these children.

The association of postnatal urinary tract dilation risk score with clinical outcomes

BACKGROUND

There are limited data on the predictive value of the consensus urinary tract dilation (UTD) score with respect to subsequent clinical diagnoses. We sought to define the relationship between postnatal UTD risk score and clinical outcomes during childhood.

METHODS

Complete ultrasound image sets from a random selection of infants aged 0-90 days undergoing initial ultrasound at a single institution for prenatal hydronephrosis between 2012 and 2014 were assigned a UTD score by 1 pediatric urologist and 1 pediatric radiologist. Urinary tract dilation risk score was analyzed for association with a composite outcome comprising urinary tract infection, vesicoureteral reflux (VUR), ureteropelvic junction obstruction, non-refluxing megaureter (NRM), ureterocele, bladder outlet obstruction (BOO), and chronic kidney disease. Surgical intervention and resolution of UTD were evaluated separately. Descriptive and survival analyses were performed.

RESULTS

Urinary tract dilation scores for 494 subjects were P0 in 23.5%, P1 in 26.5%, P2 in 23.5%, and P3 in 26.5%. Seventy-four percent were male. Median age at initial imaging was 28 days; median follow-up was 19.8 months. The composite outcome occurred in 138 of 494 patients (27.9%) and varied significantly (p < 0.001) by UTD score: 11.2% for P0, 10.7% for P1, 29.3% for P2, and 58.8% for P3. On survival analysis (Summary Figure), higher UTD grade was significantly associated with the composite outcome (hazard ratio for P3 vs. P0 was 7.4 [95% CI: 3.44-15.92, p < 0.001]). Urinary tract infection and VUR diagnosis varied by UTD score (p = 0.03 and p < 0.001, respectively). Ureteropelvic junction obstruction was diagnosed (based on MAG3 results) in 6.3% of patients, 84% of whom were P3. Non-refluxing megaureter was diagnosed in 7.7%. Ureterocele and BOO were uncommon (1.4%, and 0.6%, respectively). Surgical intervention was also associated with UTD risk, with 46% of P3 undergoing surgery vs. 1% of P0, 1% of P1, and 6% of P2 (p < 0.001). Resolution of UTD occurred in 41% (median 10.1 months) and varied significantly by UTD risk (p < 0.001).

DISCUSSION

Urinary tract dilation risk score is associated with clinical events, although ascertainment bias may influence some of the differences in outcomes, particularly for VUR, because VCUG utilization varied by the UTD group. The lack of any significant difference in outcomes between patients with UTD P0 versus P1 suggests that the P1 category could be eliminated as it does not meaningfully distinguish between outcome risk.

CONCLUSIONS

Higher UTD risk scores are strongly associated with genitourinary diagnoses during the first two years of life.

Antitumor Activity and Tolerability of hu14.18-IL2 with GMCSF and Isotretinoin in Recurrent or Refractory Neuroblastoma: A Children's Oncology Group Phase II Study

PURPOSE

Combining anti-GD2 (disialoganglioside) mAb with GM-CSF, IL2, and isotretinoin is now FDA-approved for high-risk neuroblastoma minimal residual disease (MRD) therapy. The humanized anti-GD2 antibody conjugated to IL2 (hu14.18-IL2) has clinical activity in neuroblastoma and is more effective in neuroblastoma-bearing mice than antibody and cytokine given separately. We therefore evaluated the safety, tolerability, and antitumor activity of hu14.18-IL2 given with GM-CSF and isotretinoin in a schedule similar to standard MRD therapy.

PATIENTS AND METHODS

Hu14.18-IL2 was given at the recommended phase II dose of 12 mg/m²/day on days 4-6 of a 28-day cycle with GM-CSF (250 mg/m²/dose, days 1-2 and 8-14) and isotretinoin (160 mg/m²/day, days 11-25). Tolerability was determined on the basis of the number of unacceptable toxicities observed. Response was evaluated separately for patients with disease measurable by standard radiologic criteria (stratum 1), and for patients with disease evaluable only by I¹²³-metaiodobenzylguanidine (I¹²³-MIBG) scan and/or bone marrow histology (stratum 2).

RESULTS

Fifty-two patients with recurrent or refractory neuroblastoma were enrolled; 51 were evaluable for toxicity and 45 were evaluable for response. Four patients had unacceptable toxicities, well below the protocol-defined rule for tolerability. Other grade 3 and 4 nonhematologic toxicities were expected and reversible. No responses were seen in stratum 1 (n = 14). In stratum 2 (n = 31), 5 objective responses were confirmed by central review (3 complete, 2 partial).

CONCLUSIONS

Hu14.18-IL2 given in combination with GM-CSF and isotretinoin is safe and tolerable. Patients with MIBG and/or bone marrow-only disease had a 16.1% response rate, confirming activity of the combination.

Correction to: A consensus response on the complete picture: reply to Lynøe and Eriksson

The original version on this paper contained an error. The COI statement is incorrectly presented.

Consensus statement on abusive head trauma in infants and young children

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.

Imaging of renal medullary carcinoma in children and young adults: a report from the Children's Oncology Group

BACKGROUND

Renal medullary carcinoma is a rare renal malignancy of childhood. There are no large series describing the imaging appearance of renal medullary carcinoma in children.

OBJECTIVE

To characterize the clinical and imaging features of pediatric renal medullary carcinoma at initial presentation.

MATERIALS AND METHODS

We retrospectively analyzed images of 25 pediatric patients with renal medullary carcinoma enrolled in the Children's Oncology Group renal tumors classification, biology and banking study (AREN03B2) from March 2006 to August 2016. Imaging findings of the primary mass, and patterns of locoregional and distant spread were evaluated in correlation with pathological and surgical findings.

RESULTS

Median age at presentation was 13 years (range: 6-21 years), with a male predominance (3.2:1). The overall stage of disease at initial presentation was stage 1 in 1, stage 2 in 2 and stage 4 in 22. Maximum diameter of the primary renal mass ranged from 1.6 to 10.3 cm (mean: 6.6 cm) with a slight right side predilection (1.5:1). Enlarged (>1 cm short axis) retroperitoneal lymph nodes were identified at initial staging in 20/25 (80%) cases, 10 of which were histologically confirmed while the others did not undergo surgical sampling. Enlarged lymph nodes were also identified in the mediastinum (14/25; 56%) and supraclavicular regions (4/25; 16%). Metastatic disease was present in the lungs in 19/25 (76%) and liver in 6/25 (24%). The pattern of lung metastases was pulmonary lymphangitic carcinomatosis: 10 cases (9 bilateral, 1 unilateral), pulmonary nodules with indistinct margins: 6 cases, pulmonary nodules with distinct margins: 2 cases, while 1 case had pulmonary nodules with both indistinct and distinct margins. Pulmonary lymphangitic carcinomatosis was pathologically confirmed in 4/10 cases. All cases with pulmonary lymphangitic carcinomatosis had associated enlarged mediastinal lymph nodes.

CONCLUSION

Renal medullary carcinoma in children and young adults presents at an advanced local and distant stage in the majority of patients. The diagnosis of renal medullary carcinoma should be considered when a child or young adult presents with a poorly defined/infiltrative, centrally located renal mass, especially in the setting of known sickle cell hemoglobinopathy. Distant metastases are common at initial presentation in the lungs, distant lymph nodes and liver and often involve multiple sites simultaneously. Pulmonary lymphangitic carcinomatosis, a distinctive and uncommon form of lung metastasis in children, is common in this patient population.

Imaging of Sports-related Injuries of the Lower Extremity in Pediatric Patients

With increasing participation and intensity of training in youth sports in the United States, the incidence of sports-related injuries is increasing, and the types of injuries are shifting. In this article, the authors review sports injuries of the lower extremity, including both acute and overuse injuries, that are common in or specific to the pediatric population. Common traumatic injuries that occur in individuals of all ages (eg, tears of the acetabular labrum and anterior cruciate ligament) are not addressed, although these occur routinely in pediatric sports. However, some injuries that occur almost exclusively in high-level athletes (eg, athletic pubalgia) are reviewed to increase awareness and understanding of these entities among pediatric radiologists who may not be familiar with them and thus may not look for them. Injuries are described according to their location (ie, hip, knee, or foot and ankle) and pathologic process (eg, apophysitis, osteochondritis dissecans). Examples of abnormalities and normal variants of the anatomy that are often misdiagnosed are provided. The injuries reviewed represent a common and growing subset of pathologic processes about which all pediatric and musculoskeletal radiologists should be knowledgeable. Understanding physeal injury is especially important because missed diagnoses can lead to premature physeal closure and osteoarthritis. ^©RSNA, 2016.

Preclinical molecular imaging of glutamatergic and dopaminergic neuroreceptor kinetics in obsessive compulsive disorder

BACKGROUND

Molecular neuroimaging was applied in the quinpirole rat model for compulsive checking in OCD to visualize the D2- and mGluR5-receptor occupancy with Raclopride and ABP-688 microPET/CT.

METHODS

Animals (n=48) were exposed to either saline (CTRL; 1mL/kg) or quinpirole (QP; dopamine D2-agonist, 0.5mg/kg) in a single injection (RAC and ABP acute groups) or twice-weekly during 7weeks (chronic group). Animals underwent PET/CT after the 1st injection (acute) or before initial exposure and following the 10th injection in week 5 (chronic). For the latter, each injection was paired with an open field test and video tracking.

RESULTS

The QP animals displayed a strong increase in visiting frequency (checking) in the chronic group (+699.29%) compared to the control animals. Acute administration of the drug caused significant (p<0.01) decreases in D2R occupancy in the CP (-42.03%±4.01%). Chronical exposure resulted in significantly stronger decreases in the CP (-52.29%±3.79%). Furthermore significant increases in mGluR5 occupancy were found in the CP (10.36%±4.09%), anterior cingulate cortex (13.26%±4.01%), amygdala (24.36%±6.86%), entorhinal cortex (18.49%±5.14%) and nucleus accumbens (13.8%±4.87%) of the chronic group, not present after acute exposure.

CONCLUSIONS

Compared to acute exposure, sensitisation to QP as a model for OCD differs both on a dopaminergic and glutamateric level, indicating involvement of processes such as receptor internalization and changes in extracellular availability of both neurotransmitters.

Radiologist performance in the interpretation of contrast enemas performed for Hirschsprung's disease in children >1 year of age

AIM

To evaluate the diagnostic performance of contrast enemas (CEs) for the diagnosis of Hirschsprung's disease (HD).

METHODS AND MATERIALS

CE studies performed as part of an HD workup in patients 1-18 years of age over a 10-year period were identified. All abnormal CE studies and an equal number of age-matched controls were included in the final study group. Two radiologists independently and blindly reviewed all CE studies for quality (scale of 0-3) and the presence of large colon calibre, colon redundancy, transition zone, rectosigmoid ratio, and abnormal contractions. Readers also determined whether a rectal biopsy would be recommended to confirm an HD diagnosis. Discrepancies were resolved in consensus. Findings were correlated with surgery and biopsy data.

RESULTS

Out of 834 CE studies, 38 abnormal CE studies were identified (mean age 5.9 years) and included 38 matched controls. Seventeen of 76 patients were recommended for rectal biopsy, of which five were confirmed to have HD. Twelve of 70 (17.1%) were false positives, and were clinically confirmed not to have HD. The proportion of HD in the present population was 6/834 (0.72%). Of the 17 recommended for biopsy, CE studies showed 17/17 (100%) with an abnormal rectosigmoid ratio, 16/17 (94.1%) with redundant colon, and 15/17 (88%) with large colon. Of patients not recommended for biopsy, one was diagnosed with HD, (false negative, 16.7%). The diagnostic performance of CE was 83.3% sensitivity and 82.9% specificity.

CONCLUSION

Few children >1 year of age were found to have HD and the diagnostic performance of the CE is moderately high. The CE examination is a valuable non-invasive imaging study to help exclude older children who may not have HD, thereby obviating the need for invasive rectal biopsy and surgery.

Prevalence of non-cardiovascular findings on CT angiography in children with congenital heart disease

BACKGROUND

CT angiography is gaining broader acceptance in the evaluation of children with known or suspected congenital heart disease. These studies include non-cardiovascular structures such as the mediastinum, lung parenchyma and upper abdominal organs. It is important to inspect all these structures for potential abnormalities that might be clinically important and, in some cases, may impact care plans.

OBJECTIVE

To determine the prevalence of non-cardiovascular findings in CT angiography of children with congenital heart disease.

MATERIALS AND METHODS

During 28 months, 300 consecutive children (170 males; mean age: 7.1 years, age range: 6 h-26 years), referred from a tertiary pediatric cardiology center, underwent clinically indicated CT angiography to evaluate known or suspected congenital heart disease. Slightly more than half (n = 169) of the patients were postoperative or post-intervention. Examinations were retrospectively reviewed, and non-cardiovascular findings were recorded and tabulated by organ system, congenital heart disease and operative procedure in conjunction with outcomes from medical charts.

RESULTS

Non-cardiovascular findings were identified in 83% (n = 250 / 300) of the studies for a total of 857 findings. In 221 patients (n = 73.7% of 300) a total of 813 non-cardiovascular findings were clinically significant, while in 9.7% (n = 29 / 300) of patients, 5.1% (n = 44 / 857) of the findings were nonsignificant. In 38.3% (n = 115 / 300) of patients with significant non-cardiovascular pathology, the findings were unexpected and directly impacted patient care plans. Commonly involved organs with non-cardiovascular findings were the lungs with 280 non-cardiovascular findings in 176 / 300 (58.7%) of patients, the airway with 139 non-cardiovascular findings in 103 / 300 (34.3%) of patients and the liver with 108 non-cardiovascular findings in 72 / 300 (24.0%) of patients. Syndromic associations were noted in 22% (n = 66 / 300) of the patients.

CONCLUSION

Non-cardiovascular findings are common in children with congenital heart disease who undergo CT angiography. Based upon our study population, if a child with congenital heart disease has a CT angiography, five out of six will have non-cardiovascular findings, while nearly three out of four (73.7%; 221 / 300) will have significant non-cardiovascular findings. Close attention to the non-cardiovascular structures in children with congenital heart disease presenting for a CT angiography is recommended as in nearly 40% of these children, findings were unexpected and directly altered patient care.

Dual-energy compared to single-energy CT in pediatric imaging: a phantom study for DECT clinical guidance

BACKGROUND

Dual-energy CT technology is available on scanners from several vendors and offers significant advantages over classic single-energy CT technology in multiple clinical applications. Many studies have detailed dual-energy CT applications in adults and several have evaluated the relative radiation dose performance of dual-energy CT in adult imaging. However, little has been published on dual-energy CT imaging in the pediatric population, and the relative dose performance of dual-energy CT imaging in the pediatric population is not well described.

OBJECTIVE

When evaluating dual-energy CT technology for implementation into a routine clinical pediatric imaging practice, the radiation dose implications must be considered, and when comparing relative CT dose performance, image quality must also be evaluated. Therefore the purpose of this study is to develop dual-energy CT scan protocols based on our optimized single-energy scan protocols and compare the dose.

MATERIALS AND METHODS

We scanned the head, chest and abdomen regions of pediatric-size anthropomorphic phantoms with contrast inserts, using our optimized single-energy clinical imaging protocols on a Siemens Flash® CT scanner. We then scanned the phantoms in dual-energy mode using matching image-quality reference settings. The effective CT dose index volume (CTDI_vol) of the scans was used as a surrogate for relative dose in comparing the single- and dual-energy scans. Additionally, we evaluated image quality using visual assessment and contrast-to-noise ratio.

RESULTS

Dual-energy CT scans of the head and abdomen were dose-neutral for all three phantoms. Dual-energy CT scans of the chest showed a relative dose increase over the single-energy scan for 1- and 5-year-old child-based age-equivalent phantoms, ranging 11-20%. Quantitative analysis of image quality showed no statistically significant difference in image quality between the single-energy and dual-energy scans. There was no clinically significant difference in image quality by visual assessment.

CONCLUSION

Dual-energy CT is dose-neutral in imaging the head and abdomen in children. It is not dose-neutral in chest imaging of very small children. With a better understanding of the dose consequences of converting single-energy protocols to dual-energy protocols we can begin to implement clinical dual-energy CT and utilize its unique capabilities in pediatric imaging.

Milestones on a Shoestring: A Cost-Effective, Semi-automated Implementation of the New ACGME Requirements for Radiology

RATIONALE AND OBJECTIVES

The advent of the ACGME's Next Accreditation System represents a significant new challenge for residencies and fellowships, owing to its requirements for more complex and detailed information.

MATERIAL AND METHODS

We developed a system of online assessment tools to provide comprehensive coverage of the twelve ACGME Milestones and digitized them using freely available cloud-based productivity tools. These tools include a combination of point-of-care procedural assessments, electronic quizzes, online modules, and other data entry forms. Using free statistical analytic tools, we also developed an automated system for management, processing, and data reporting.

RESULTS

After one year of use, our Milestones project has resulted in the submission of over 20,000 individual data points. The use of automated statistical methods to generate resident-specific profiles has allowed for dynamic reports of individual residents' progress. These profiles both summarize data and also allow program directors access to more granular information as needed.

CONCLUSION

Informatics-driven strategies for data assessment and processing represent feasible solutions to Milestones assessment and analysis, reducing the potential administrative burden for program directors, residents, and staff.

Comparison of diagnostic performance of CT and MRI for abdominal staging of pediatric renal tumors: a report from the Children's Oncology Group

BACKGROUND

CT and MRI are both used for abdominal staging of pediatric renal tumors. The diagnostic performance of the two modalities for local and regional staging of renal tumors has not been systematically evaluated.

OBJECTIVE

To compare the diagnostic performance of CT and MRI for local staging of pediatric renal tumors.

MATERIALS AND METHODS

The study population was derived from the AREN03B2 study of the Children's Oncology Group. Baseline abdominal imaging performed with both CT and MRI within 30 days of nephrectomy was available for retrospective review in 82 renal tumor cases. Each case was evaluated for capsular penetration, lymph node metastasis, tumor thrombus, preoperative tumor rupture, and synchronous contralateral lesions. The surgical and pathological findings at central review were the reference standard.

RESULTS

The sensitivity of CT and MRI for detecting capsular penetration was 68.6% and 62.9%, respectively (P = 0.73), while specificity was 86.5% and 83.8% (P = 1.0). The sensitivity of CT and MRI for detecting lymph node metastasis was 76.5% and 52.9% (P = 0.22), and specificity was 90.4% and 92.3% (P = 1.0). Synchronous contralateral lesions were identified by CT in 4/9 cases and by MRI in 7/9 cases.

CONCLUSION

CT and MRI have similar diagnostic performance for detection of lymph node metastasis and capsular penetration. MR detected more contralateral synchronous lesions; however these were present in a very small number of cases. Either modality can be used for initial loco-regional staging of pediatric renal tumors.

The effects of bismuth breast shields in conjunction with automatic tube current modulation in CT imaging

BACKGROUND

There are mechanisms within CT scanners and shielding that can be used to lower dose to patients.

OBJECTIVE

The objective of our study was to evaluate the dose changes and image quality with and without a breast shield for multidetector CT of the chest with angular tube current modulation.

MATERIALS AND METHODS

An anthropomorphic 5-year-old phantom was scanned with and without bismuth breast shielding and with and without angular tube current modulation. Image quality was assessed by measuring signal-to-noise ratio and contrast-to-noise ratio as well as measuring qualitatively. ANOVA single-factor p-value analysis of paired datasets was used for the statistical analysis.

RESULTS

The breast shielding and angular tube current modulation resulted in a dose reduction to 85% for the breast and 90% overall. Although no qualitative differences were noted with and without the breast shielding used with angular tube current modulation, there were statistically significant differences in the contrast-to-noise ratio and CT numbers.

CONCLUSIONS

When used with angular tube current modulation, breast shields influence the contrast-to-noise ratio and CT numbers, and therefore should not be used for chest CT. Greater dose reduction can be obtained by reducing the reference mAs (or reference noise index).

Foreign bodies: radiopaque compared to what?

BACKGROUND

The term "radiopaque" is commonly used when discussing foreign bodies and lists of radiopaque and non-radiopaque materials are sometimes created, but radiopacity is not a binary concept. A more fundamental understanding of radiopacity is necessary for the work-up of foreign bodies.

OBJECTIVE

To demonstrate that "radiopaque" is a relative term.

MATERIALS AND METHODS

Twenty foreign bodies of various sizes, shapes and materials were placed in a basin. Radiographs were obtained of the objects with 0, 2.5, 5 and 10 cm depth of water in the basin to simulate the appearance of a foreign body in human tissue. The progressively changing appearance of the objects was observed.

RESULTS

All of the objects were radiographically visible in the empty basin. Different objects demonstrated different appearances when immersed in progressively deeper levels of water, illustrating the effect of the surrounding water as well as the effects of object shape, size, orientation and composition.

CONCLUSION

The concept of radiopacity seems simple and the term "radiopaque" is sometimes used to describe an all or none phenomenon. However, radiopacity is a comparative concept implying relative X-ray attenuation. Accurate understanding of the radiographic appearance of foreign bodies requires one to keep in mind the concepts of relative X-ray attenuation and contrast resolution.

Müllerian duct and related anomalies in children and adolescents

Although many Müllerian duct anomalies do not require treatment, surgical intervention is sometimes necessary to enable sexual activity or to preserve fertility. The identification of these anomalies is important for optimal clinical management or surgical treatment. Magnetic resonance (MR) imaging is a robust method for adequately evaluating and characterizing uterine and vaginal anomalies. The information provided by MR imaging allows for a more complete understanding of the malformation, facilitating management decisions and potentially changing the outcome. In this article, the embryology, classification, and MR imaging findings of Müllerian duct and related anomalies in children and adolescents are reviewed.

Impact of clinical history on chest radiograph interpretation

BACKGROUND

The inclusion of clinical information may have unrecognized influence in the interpretation of diagnostic testing.

OBJECTIVE

The objective of the study was to determine the impact of clinical history on chest radiograph interpretation in the diagnosis of pneumonia.

DESIGN

Prospective case-based study.

METHODS

Radiologists interpreted 110 radiographs of children evaluated for suspicion of pneumonia. Clinical information was withheld during the first interpretation. After 6 months the radiographs were reviewed with clinical information. Radiologists reported on pneumonia indicators described by the World Health Organization (ie, any infiltrate, alveolar infiltrate, interstitial infiltrate, air bronchograms, hilar adenopathy, pleural effusion).

SETTING

Children's Hospital of Philadelphia and Boston Children's Hospital.

PARTICIPANTS

Six board-certified radiologists.

OUTCOME MEASURES

Inter- and inter-rater reliability were assessed using the kappa statistic.

RESULTS

The addition of clinical history did not have a substantial impact on the inter-rater reliability in the identification of any infiltrate, alveolar infiltrate, interstitial infiltrate, pleural effusion, or hilar adenopathy. Inter-rater reliability in the identification of air bronchograms improved from fair (k = 0.32) to moderate (k = 0.53). Intra-rater reliability for the identification of alveolar infiltrate remained substantial to almost perfect for all 6 raters with and without clinical information. One rater had a decrease in inter-rater reliability from almost perfect (k = 1.0) to fair (k = 0.21) in the identification of interstitial infiltrate with the addition of clinical history.

CONCLUSIONS

Alveolar infiltrate and pleural effusion are findings with high intra- and inter-rater reliability in the diagnosis of bacterial pneumonia. The addition of clinical information did not have a substantial impact on the reliability of these findings.

Comparison of [123I]MIBG and [131I]MIBG for imaging of neuroblastoma and other neural crest tumors

Meta-iodobenzylguanidine (MIBG), an analog of the adrenergic neurotransmitter norepinephrine, has proven a valuable imaging agent for neuroendocrine and neural crest tumors. Over the past 3 decades, MIBG labeled with [131I] or [123I] has been used widely in imaging of neuroblastoma and pheochromocytoma. Before September 2008 [131I]MIBG was approved as a diagnostic agent only in the US. Due to the excellent physical characteristics of [123I] for imaging with modern scintillation cameras, [123I]MIBG is theoretically more suitable than [131I]MIBG in detecting tumors. In practice, use of [123I]MIBG or [131I]MIBG for diagnostic studies depends on availability and local preference. This review compares [123I]MIBG with [131I]MIBG in imaging of neuroblastoma and other neural crest tumors and also the physical properties of relevant radioisotopes. Dosimetry and scanning protocols of [123I]MIBG and [131I]MIBG, along with their value in depicting disease extent, assessing treatment response and predicting survival are also compared. The performance of post-therapy high-activity [131I]MIBG scans in lesion detectability is also addressed.

Variability in the interpretation of chest radiographs for the diagnosis of pneumonia in children

BACKGROUND

Although chest radiography is commonly used to establish the diagnosis of pneumonia in children, the reliability of radiographic findings among radiologists is not well described.

OBJECTIVE

We sought to evaluate the inter-rater and intra-rater reliability of radiographic features commonly described by radiologists in childhood pneumonia.

METHODS

Prospective case-based study. One hundred and ten radiographs of children evaluated in a pediatric emergency department for suspicion of pneumonia were interpreted by six radiologists at two academic children's hospitals. Radiologists were blinded to the clinical history. Reliability of standardized radiographic features was evaluated using the kappa statistic.

RESULTS

The radiographic finding of an alveolar infiltrate demonstrated substantial reliability among radiologists (κ = 0.69). The presence of 'any infiltrate' and pleural effusion demonstrated moderate reliability (κ = 0.47 and k=0.45, respectively). Other radiographic features were less reliable: air bronchograms (κ = 0.32), hilar adenopathy (κ = 0.21), and interstitial infiltrate (κ = 0.14). Similarly, the finding of alveolar infiltrate demonstrated substantial intra-rater reliability upon review of ten duplicate radiographs, whereas interstitial infiltrate was less reliable.

CONCLUSION

The radiographic finding of an alveolar infiltrate is very reliable among pediatric radiologists, whereas the finding of an interstitial infiltrate is less reliable.

Postnatal imaging of neonates with prenatally diagnosed genitourinary abnormalities: a practical approach

The advent of prenatal US and, more recently, fetal MRI has changed our pattern of referrals. In the current clinical algorithms, most neonates evaluated for genitourinary abnormalities are asymptomatic. These infants are referred for multidisciplinary consultation, imaging and surveillance. Evaluation of these children commences following pertinent review of available prenatal studies; this is appropriate, as in certain instances prenatally gathered information of potential prognostic significance can be inferred or can obviate the need for multiple examinations. US remains the first-line imaging modality for diagnosing urinary abnormalities in neonates and young infants, although it offers primarily morphological assessment. However, US coupled with MAG-3 scanning results in a powerful combination that provides anatomical and functional information. Recently, MRI and MR urography have been increasingly regarded as one-stop-shop examinations that can deliver both anatomical and functional information, and play an increasing role in the evaluation of ureteral ectopia and genital anomalies. Fluoroscopic examinations are reserved to exclude vesicoureteral reflux, to delineate urethral obstruction or to provide additional information to support a diagnosis. A practical approach to postnatal imaging of the neonate is discussed and the important genitourinary anomalies in this age group are presented and illustrated.

Imaging of pediatric ovarian neoplasms

We review the clinical and imaging characteristics of the most common ovarian neoplasms in children and adolescents. Because of the widespread use of diagnostic imaging, incidental ovarian neoplasms might be encountered during the evaluation of abdominal pain, trauma or other indications and might pose a diagnostic dilemma. Conducting adequate imaging studies under these conditions is important, as management strategies differ according to the size and appearance of the lesion as well as the age of the patient. US dominates in gynecological imaging because of its excellent visualization, absence of ionizing radiation and sedation risks and comparatively low cost. For further examination of indeterminate lesions found using US, MRI is being used more progressively in this field, particularly for the evaluation of complex pelvic masses with the aim of distinguishing benign and malignant conditions and conditions requiring surgical intervention. CT is reserved primarily for tumor staging and follow-up and for emergency situations.

Imaging infection and inflammation in children with (18)F-FDG PET and (18)F-FDG PET/CT

The goal of this article is to delineate indications for (18)F-FDG PET/CT pertaining to inflammation in the pediatric population, with emphasis on those that have been described in the literature. The limitations of (18)F-FDG PET/CT in this type of evaluation are also described, and the importance of using as low a dose as feasible is discussed. After reading this article, the reader should be able to list several clinical situations in which (18)F-FDG PET/CT may be appropriate, describe some limitations of (18)F-FDG PET/CT, and explain why dose is particularly important in the pediatric population.