The brain in myotonic dystrophy 1 and 2: evidence for a predominant white matter disease

Myotonic dystrophy types 1 and 2 are progressive multisystemic disorders with potential brain involvement. We compared 22 myotonic dystrophy type 1 and 22 myotonic dystrophy type 2 clinically and neuropsychologically well-characterized patients and a corresponding healthy control group using structural brain magnetic resonance imaging at 3 T (T₁/T₂/diffusion-weighted). Voxel-based morphometry and diffusion tensor imaging with tract-based spatial statistics were applied for voxel-wise analysis of cerebral grey and white matter affection (P_corrected < 0.05). We further examined the association of structural brain changes with clinical and neuropsychological data. White matter lesions rated visually were more prevalent and severe in myotonic dystrophy type 1 compared with controls, with frontal white matter most prominently affected in both disorders, and temporal lesions restricted to myotonic dystrophy type 1. Voxel-based morphometry analyses demonstrated extensive white matter involvement in all cerebral lobes, brainstem and corpus callosum in myotonic dystrophy types 1 and 2, while grey matter decrease (cortical areas, thalamus, putamen) was restricted to myotonic dystrophy type 1. Accordingly, we found more prominent white matter affection in myotonic dystrophy type 1 than myotonic dystrophy type 2 by diffusion tensor imaging. Association fibres throughout the whole brain, limbic system fibre tracts, the callosal body and projection fibres (e.g. internal/external capsules) were affected in myotonic dystrophy types 1 and 2. Central motor pathways were exclusively impaired in myotonic dystrophy type 1. We found mild executive and attentional deficits in our patients when neuropsychological tests were corrected for manual motor dysfunctioning. Regression analyses revealed associations of white matter affection with several clinical parameters in both disease entities, but not with neuropsychological performance. We showed that depressed mood and fatigue were more prominent in patients with myotonic dystrophy type 1 with less white matter affection (early disease stages), contrary to patients with myotonic dystrophy type 2. Thus, depression in myotonic dystrophies might be a reactive adjustment disorder rather than a direct consequence of structural brain damage. Associations of white matter affection with age/disease duration as well as patterns of cerebral water diffusion parameters pointed towards an ongoing process of myelin destruction and/or axonal loss in our cross-sectional study design. Our data suggest that both myotonic dystrophy types 1 and 2 are serious white matter diseases with prominent callosal body and limbic system affection. White matter changes dominated the extent of grey matter changes, which might argue against Wallerian degeneration as the major cause of white matter affection in myotonic dystrophies.

Postsurgical surveillance of patients with FIGO stage I/II endometrial adenocarcinoma

OBJECTIVE

To examine the effect of postsurgical surveillance on survival of patients with FIGO stage I/II endometrial adenocarcinoma.

METHODS

We examined the records of 354 patients who underwent primary surgical therapy for FIGO stage I/II endometrial adenocarcinoma. In patients who developed recurrent disease, we determined whether symptoms or signs of disease were present at recurrence and whether there was evidence of disease on Pap smear or chest radiograph.

RESULTS

Among the 354 patients in this study, 44 (12%) developed recurrent disease. Sites of recurrence included 12 (27%) isolated vaginal, 12 (27%) pelvic with vagina or abdomen, 4 (10%) isolated lung, 13 (29%) pelvic/abdominal with other distant sites, and 3 (7%) other distant sites. At diagnosis of recurrence 61% of patients had symptoms related to their cancer, 68% had physical exam findings suggestive of recurrence, and 84% had symptoms and/or signs. Findings consistent with recurrent cancer were detected by Pap smear in 25% and on chest radiograph in 20%. Among the 44 patients who developed recurrent disease, 8 (18%) remain alive without evidence of disease, including 6/12 (50%) with isolated vaginal disease and 2/34 (6%) with other patterns of recurrent disease (P = 0.01). Among the 12 patients with isolated vaginal recurrence, 1/3 (33%) in whom recurrent disease was diagnosed by Pap smear alone was salvaged compared to 5/9 (56%) who had symptoms or signs of vaginal recurrence. None of the three patients in whom an abnormal chest radiograph was the only evidence of recurrence survived.

CONCLUSIONS

Because of the low recurrence rate of FIGO stage I/II endometrial cancer and the paucity of effective second-line treatment, surveillance Pap smears and chest radiographs appear to have little impact on survival. Although few asymptomatic potentially curable recurrences were detected due to surveillance examinations, the value of psychological reassurance associated with a normal examination is difficult to quantitate.