European Society of Breast Cancer Specialists/Advanced Breast Cancer Global Alliance quality indicators for metastatic breast cancer care

AIMS

Improvement in the care of patients with metastatic breast cancer (MBC) can only occur if the adequate quality of care is implemented and verified, including access to multidisciplinary, specialised care given in accordance with high-quality guidelines. To this purpose, European Society of Breast Cancer Specialists and the Advanced Breast Cancer Global Alliance joined efforts to develop the first set of quality indicators (QI) specifically for MBC that should be routinely measured and evaluated to ensure that breast cancer centres meet the required standards.

METHODS

A working group of multidisciplinary European experts in breast cancer met to discuss each identified QI, reporting the definition, the minimum and target standard for breast cancer centres to achieve, and the motivation for selection. The level of evidence was determined according to the short version of the United States Agency for Healthcare Research and Quality classification.

RESULTS

QI to measure access to and involvement in multidisciplinary and supportive care, appropriate pathological characterisation of disease, systemic therapies and radiotherapy were developed with the consensus of the working group.

CONCLUSIONS

This is the first effort of a multistep project that aims to have QI for MBC routinely measured and evaluated to ensure that breast cancer centres achieve mandated standards in the care of patients with metastatic disease.

Comparison of Intra- and Inter-Patient Intensity Standardization Methods for Multi-Parametric Whole-Body MRI

OBJECTIVE

To test and compare different intensity standardization approaches for whole-body multi-parametric MRI, allowing for the compensation of univocal representation of image intensities between scans, which pose problems in image quantification, assessment of changes between a baseline and follow-up scan and hinder performance of image processing and machine learning algorithms. 

Approach: In this work, we present a comparison on the accuracy of intensity standardization approaches with increasing complexity, for intra- and inter-patient multi-parametric whole-body MRI. Several approaches were used: z-scoring of the intensities, piecewise linear mapping and deformable mapping of intensity distributions into established reference intensity space. Additionally, the use reference image and average population distribution reference; as well as, whole image and region of interest standardization approaches were investigated. All methods were validated on a data set of 18 whole-body anatomical and diffusion-weighted MR scans consisting of baseline and follow-up examinations acquired from advanced prostate cancer patients and healthy volunteers. 

Main results: The piecewise linear intensity standardisation approach provided the best compromise between standardization accuracy and method stability, with average deviations in intensity profile of 0.011-0.027 and mean absolute difference of 0.29-0.37 standard score (intra-patient) and 0.014-0.056 (inter-patient), depending on the type of used MR modality. 

Significance: Linear piecewise approaches showed the overall best performance across multiple validation metrics, mostly because of its robustness. The inter-patient standardization proved to perform better when using population average reference image; in contrary to intra-patient approach, where the best results were achieved by standardizing towards a reference image taken as the baseline scan.

Standardised lesion segmentation for imaging biomarker quantitation: a consensus recommendation from ESR and EORTC

BACKGROUND

Lesion/tissue segmentation on digital medical images enables biomarker extraction, image-guided therapy delivery, treatment response measurement, and training/validation for developing artificial intelligence algorithms and workflows. To ensure data reproducibility, criteria for standardised segmentation are critical but currently unavailable.

METHODS

A modified Delphi process initiated by the European Imaging Biomarker Alliance (EIBALL) of the European Society of Radiology (ESR) and the European Organisation for Research and Treatment of Cancer (EORTC) Imaging Group was undertaken. Three multidisciplinary task forces addressed modality and image acquisition, segmentation methodology itself, and standards and logistics. Devised survey questions were fed via a facilitator to expert participants. The 58 respondents to Round 1 were invited to participate in Rounds 2-4. Subsequent rounds were informed by responses of previous rounds.

RESULTS/CONCLUSIONS

Items with ≥ 75% consensus are considered a recommendation. These include system performance certification, thresholds for image signal-to-noise, contrast-to-noise and tumour-to-background ratios, spatial resolution, and artefact levels. Direct, iterative, and machine or deep learning reconstruction methods, use of a mixture of CE marked and verified research tools were agreed and use of specified reference standards and validation processes considered essential. Operator training and refreshment were considered mandatory for clinical trials and clinical research. Items with a 60-74% agreement require reporting (site-specific accreditation for clinical research, minimal pixel number within lesion segmented, use of post-reconstruction algorithms, operator training refreshment for clinical practice). Items with ≤ 60% agreement are outside current recommendations for segmentation (frequency of system performance tests, use of only CE-marked tools, board certification of operators, frequency of operator refresher training). Recommendations by anatomical area are also specified.

Twenty Years On: RECIST as a Biomarker of Response in Solid Tumours an EORTC Imaging Group - ESOI Joint Paper

Response evaluation criteria in solid tumours (RECIST) v1.1 are currently the reference standard for evaluating efficacy of therapies in patients with solid tumours who are included in clinical trials, and they are widely used and accepted by regulatory agencies. This expert statement discusses the principles underlying RECIST, as well as their reproducibility and limitations. While the RECIST framework may not be perfect, the scientific bases for the anticancer drugs that have been approved using a RECIST-based surrogate endpoint remain valid. Importantly, changes in measurement have to meet thresholds defined by RECIST for response classification within thus partly circumventing the problems of measurement variability. The RECIST framework also applies to clinical patients in individual settings even though the relationship between tumour size changes and outcome from cohort studies is not necessarily translatable to individual cases. As reproducibility of RECIST measurements is impacted by reader experience, choice of target lesions and detection/interpretation of new lesions, it can result in patients changing response categories when measurements are near threshold values or if new lesions are missed or incorrectly interpreted. There are several situations where RECIST will fail to evaluate treatment-induced changes correctly; knowledge and understanding of these is crucial for correct interpretation. Also, some patterns of response/progression cannot be correctly documented by RECIST, particularly in relation to organ-site (e.g. bone without associated soft-tissue lesion) and treatment type (e.g. focal therapies). These require specialist reader experience and communication with oncologists to determine the actual impact of the therapy and best evaluation strategy. In such situations, alternative imaging markers for tumour response may be used but the sources of variability of individual imaging techniques need to be known and accounted for. Communication between imaging experts and oncologists regarding the level of confidence in a biomarker is essential for the correct interpretation of a biomarker and its application to clinical decision-making. Though measurement automation is desirable and potentially reduces the variability of results, associated technical difficulties must be overcome, and human adjudications may be required.

Semi-quantitative CT scoring of nailed shaft fractures during normal healing and in non-unions: comparison with radiographic scoring

PURPOSE

To compare tomographic (TUS) with radiographic (RUS) union scores in nailed shaft fractures during normal healing and in non-unions.

METHODS

Two radiologists blinded to fracture age separately determined RUS and TUS in nailed femoral or tibial shaft fractures by analyzing the radiographic and CT examinations obtained in 47 patients during normal healing (early fracture group; 24 study participants, 17 men,19 tibias, mean fracture-CT delay 109 ± 57 days [42-204 days]) and in surgically proven non-united fractures (late fracture group, 23 patients, 14 men, 12 tibias, mean fracture-CT delay 565 ± 519 days[180-1983 days]). In both study groups, we determined the inter- and intra-observer agreement of RUS and TUS and compared TUS with RUS.

RESULTS

Intra- and inter-observer agreement of RUS and TUS was very good in the early fracture group and good in the late fracture group for both readers. TUS correlated with RUS substantially in the early fracture group and only weakly in the late fracture group. TUS was statistically significantly lower than RUS in study participants with RUS ≥ 8 or 9 for R2 only and ≥ 10 for both readers in the early fracture group and in patients with RUS ≥ 8, 9 or 10 in the late fracture group for both readers.

CONCLUSION

RUS and TUS of nailed shaft fractures during normal healing or in non-unions are both feasible and reproducible. They yield similar values in fractures with no or limited callus. TUS yields lower values than RUS in fractures with callus.

Detection and Characterization of Musculoskeletal Cancer Using Whole-Body Magnetic Resonance Imaging

Whole-body magnetic resonance imaging (WB-MRI) is gradually being integrated into clinical pathways for the detection, characterization, and staging of malignant tumors including those arising in the musculoskeletal (MSK) system. Although further developments and research are needed, it is now recognized that WB-MRI enables reliable, sensitive, and specific detection and quantification of disease burden, with clinical applications for a variety of disease types and a particular application for skeletal involvement. Advances in imaging techniques now allow the reliable incorporation of WB-MRI into clinical pathways, and guidelines recommending its use are emerging. This review assesses the benefits, clinical applications, limitations, and future capabilities of WB-MRI in the context of other next-generation imaging modalities, as a qualitative and quantitative tool for the detection and characterization of skeletal and soft tissue MSK malignancies.

Total en bloc spondylectomy of T11 and spine shortening performed on a 17-month-old patient: art of the possible

STUDY DESIGN

Case report.

PURPOSE

The authors used spine shortening as an alternative strategy to intercalary graft fixation to restore permanent spine stability for a 17-month-old infant who received total en bloc spondylectomy (TES) of T11 to treat an embryonic rhabdomyosarcoma. TES involves complete removal of vertebra, compensated by spine reconstruction using intercalary allografts and permanent posterior instrumentation, which is not possible for skeletally immature patients with high growth potential and non-ossified vertebrae.

METHODS

Surgery was performed over two consecutive days. During the first day, the tumor was released from its dorsal attachments through the posterior approach. During the second day, the tumor was dissected and excised through the anterior approach, leaving a gap between T10 and T12. The two vertebrae were then drawn toward each other until the gap was bridged. The dural sac slipped into the canal under T10 and T12 with no observable kinking.

RESULTS

Fifteen weeks after surgery, thoraco-abdominal CT confirmed fusion of the T10 and T12 vertebral bodies. Three years later, the patient lives a normal life with no major neurological deficits or recurrence of sarcoma.

CONCLUSIONS

This case report is the first to demonstrate the feasibility of TES with spine shortening of an entire thoracic segment without spine kinking or damage in an infant. This unprecedented surgical technique allowed complete removal of an embryonic rhabdomyosarcoma, while granting rapid stability and growth potential.

LEVEL OF EVIDENCE

IV.

Consensus on molecular imaging and theranostics in prostate cancer

Rapid developments in imaging and treatment with radiopharmaceuticals targeting prostate cancer pose issues for the development of guidelines for their appropriate use. To tackle this problem, international experts representing medical oncologists, urologists, radiation oncologists, radiologists, and nuclear medicine specialists convened at the European Association of Nuclear Medicine Focus 1 meeting to deliver a balanced perspective on available data and clinical experience of imaging in prostate cancer, which had been supported by a systematic review of the literature and a modified Delphi process. Relevant conclusions included the following: diphosphonate bone scanning and contrast-enhanced CT are mentioned but rarely recommended for most patients in clinical guidelines; MRI (whole-body or multiparametric) and prostate cancer-targeted PET are frequently suggested, but the specific contexts in which these methods affect practice are not established; sodium fluoride-18 for PET-CT bone scanning is not widely advocated, whereas gallium-68 or fluorine-18 prostate-specific membrane antigen gain acceptance; and, palliative treatment with bone targeting radiopharmaceuticals (rhenium-186, samarium-153, or strontium-89) have largely been replaced by radium-223 on the basis of the survival benefit that was reported in prospective trials, and by other systemic therapies with proven survival benefits. Although the advances in MRI and PET-CT have improved the accuracy of imaging, the effects of these new methods on clinical outcomes remains to be established. Improved communication between imagers and clinicians and more multidisciplinary input in clinical trial design are essential to encourage imaging insights into clinical decision making.

Aerococcus urinae: an underestimated cause of spine infection? Case report and review of the literature

OBJECTIVE AND IMPORTANCE

New methods of microbiology identification as MALDI-TOF MS increased the rate of Aerococci detection in microbiological samples making this germ an emerging pathogen. The purpose of this case report and literature review is to highlight the role of A. urinae in spine infection and discuss the management of this type of infection.

CLINICAL PRESENTATION AND INTERVENTION

A 32-year-old man, with a medical history of paraplegia secondary to a relapsing form of multiple sclerosis, was admitted because of lower back-pain following complaints suggestive of urinary tract infection. Spondilodiscitis was diagnosed and Aerococcus urinae was identified from bone culture. The patient improved after surgery and appropriate antibiotherapy.

CONCLUSION

A. urinae is currently more frequently identified since the introduction of MALDI-TOF MS in routine laboratories. Serious infections as endocarditis, bacteremia and spondylodiscitis have been reported usually in patients with predisposing conditions. This pathogen can be successfully treated with β-lactam antibiotics which can be replaced by vancomycin in case of penicillin allergy.

Abstract P3-13-19: Isolated sternal metastases: The place of surgical resection

Background: Solitary sternal metastases from breast cancer are found in approximately 1.9 to 2.5 % of all advanced breast cancer cases. According to the latest AJCC classification, they are still considered as stage IV disease, but their prognosis is better in the absence of other foci of metastatic disease. Their treatment still remains controversial.

Material and methods: This is a monocentric retrospective study performed in our breast clinic and approved by our ethics committee. Twelve patients were included in this study between 2010 and 2015; 11 had a metachronous solitary sternal metastasis and 1 had a synchronous metastatic sternal lesion. Complete restaging was negative in all patients for other metastatic lesions. The extent of resection (different parts of the sternum and frequently also adjacent rib cartilages) necessary to obtain free margins was estimated preoperatively on MRI images focused with adequate sequences. All the patients underwent a large sternal resection and a chest wall reconstruction integrated in a multimodal approach.

Characteristics of the patients and of the tumors were studied.

The major outcomes studied were disease-free (DFS) and overall survival (OS).

Results: The mean interval between the initial diagnosis of breast cancer and the discovery of sternal metastasis was 115 months. After surgical resection, free margins were obtained in 10 patients. No post-operative complications were observed except for persistent thoracic pain in one patient with a medical history of chronic pain. Excellent cosmetic and functional outcomes were obtained without significant impairment of respiratory function. Ten patients received chemotherapy pre- or postoperatively. All the tumors expressed ER and /or PgR receptors, and endocrine therapy was administered in all patients.

Mean duration of follow-up was 25 months (9-51 months). Three patients presented distant recurrences: 2 liver lesions and 1 cervical nodal recurrence with pericardic effusion. Out of these 3 patients, 1 died after 51 months. Currently the DFS of this small study is 75 % and the OS is 91.6 %.

Conclusion: Treatment of isolated sternal metastases of breast cancer must be based on a multidisciplinary strategy.

Sternectomy and multilayered chest wall reconstruction (with different types of meshes and flaps) could be a curative approach in highly selected patients with no other metastatic lesions. In this group of patients, the good prognosis observed could be due to a different mechanism of dissemination, based on lymphatic rather than hematogenic diffusion.

Longer follow-up and prospective studies are needed to confirm these encouraging results.

Citation Format: Berliere M, Taburiaux L, Lacroix V, Gerday A, Coyette M, Lecouvet F, Piette P, Galant C, Duhoux F, Lengele B. Isolated sternal metastases: The place of surgical resection [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-19.

Pseudoaneurysms after Ankle Sprain: Report of Three Cases Successfully Cured by Nonsurgical Treatment

Pseudoaneurysm is a rare complication of ankle sprain, with 18 case reports published in the current literature. In the vast majority of the cases, they were treated surgically. We present 3 cases of pseudoaneurysm following ankle sprain, treated by nonsurgical methods in 2 cases, and spontaneously healed in another. The diagnosis was made between 2 and 4 weeks after traumatism, by ultrasonography and arteriography in 2 cases, and only by ultrasonography in a third case. The pseudoaneurysms originated respectively from the perforating fibular artery, the dorsal pedis artery, and a lateral malleolar artery. Largest diameters of the pseudoaneurysms ranged from 2.4 to 6 cm. Patients were successfully treated by thrombin injection in a case and by coil embolization in another. Spontaneous thrombosis was demonstrated at follow-up in the third case. These cases suggest that a nonsurgical treatment can be considered for pseudoaneurysms complicating ankle sprains.

Self-resolving focal non-ossifying myositis: a poorly known clinical and imaging entity diagnosed with MRI

Background

Focal myositis is a rare benign inflammatory pseudotumor, presenting as a painful nodular mass within a muscle, and characterized by spontaneous resolution within weeks.

Purpose

To assess the clinical and imaging findings of focal nodular myositis simulating a neoplasm at clinical examination, with no history of trauma.

Material and Methods

This study describes the locations and appearance at ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) of this condition in a series of five patients.

Results

MRI and US displayed a solid intramuscular “tumor” and suggested a continuum between the proximal and distal muscle fibers that appeared thickened within the nodular lesion, a sign that has been reported in myositis ossificans. MRI showed edema in adjacent muscles and soft tissues, as well as intense enhancement of the mass. Intense vascular flows were seen at Doppler analysis. CT did not reveal the appearance of peripheral ossifications, ruling out the diagnosis of myositis ossificans. In some patients, the diagnosis of sarcoma had been suggested as possible by the radiologist. Imaging follow-up with MRI showed complete resolution of the masses over several weeks, thus avoiding a biopsy; no recurrence was observed at long-term follow-up (more than 24 months).

Conclusion

This paper highlights MRI and US findings in focal non-ossifying myositis, and emphasizes the role of MRI in suggesting this diagnosis, leading to the careful follow-up of the lesion until its resolution, and ruling out more aggressive lesions.

Charcot spinal arthropathy in a diabetic patient

We report a case of Charcot spinal arthropathy in a diabetic patient and emphasize the clinical reasoning leading to the diagnosis, discuss the differential diagnosis, and insist on the crucial role of the radiologist and pathologist which allows the distinction between Charcot spinal arthropathy and infectious or tumoural disorders of the spine.

Imaging ACL reconstructions and their complications

Examination of ligament reconstructions, particularly of the anterior cruciate ligament (ACL), are common situations in everyday knee imaging practice. Knowledge of normal appearances, the expected changes over time and the potential complications of these plasties are essential. MRI is the imaging method of choice. This article illustrates the main complications specific to this procedure: suboptimal positioning of the femoral or tibial tunnels, impingement between the graft and bony contours, rupture (partial or complete) of the plasty due to friction or injury, arthrofibrosis and particularly the "Cyclops" syndrome, fragmentation or migration of the fixation materials and a granulomatous reaction to biomaterials.

Prevention of bone metastases in patients with high-risk nonmetastatic prostate cancer treated with zoledronic acid: efficacy and safety results of the Zometa European Study (ZEUS)

BACKGROUND

Patients with high-risk localised prostate cancer (PCa) are at risk of developing bone metastases (BMs). Zoledronic acid (ZA) significantly reduces the incidence of skeletal complications in castration-resistant metastatic PCa versus placebo.

OBJECTIVE

To investigate ZA for the prevention of BMs in high-risk localised PCa.

DESIGN, SETTING, AND PARTICIPANTS

Randomised open-label multinational study with patients having at least one of the following: prostate-specific antigen ≥20 ng/ml, node-positive disease, or Gleason score 8-10.

INTERVENTION

Standard PCa therapy alone or combined with 4mg ZA intravenously every 3 mo for ≤4 yr.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

BMs were assessed using locally evaluated bone-imaging procedures (BIPs), with subsequent blinded central review. Patients with BMs, time to BMs, overall survival, and adverse events were compared between treatment groups.

RESULTS AND LIMITATIONS

A total of 1393 of 1433 randomised patients were used for intention-to-treat (ITT) efficacy analyses, with 1040 patients with BIP-BM outcome status at 4±0.5 yr. The local urologist/radiologist diagnosed BIP-BMs in 88 of 515 patients (17.1%) in the ZA group and 89 of 525 patients (17.0%) in the control group (chi-square test: p=0.95), with a difference between proportions of 0.1% (95% confidence interval [CI], -4.4 to 4.7) in favour of the control group. In the ITT population (n=1393), the Kaplan-Meier estimated proportion of BMs after a median follow-up of 4.8 yr was 14.7% in the ZA group versus 13.2% in the control group (log-rank: p=0.65). Low hot spot numbers on bone scans were confirmed as metastases with additional imaging. Central reviews of BIPs were possible only on a subset of patients.

CONCLUSIONS

ZA administered every 3 mo was demonstrated to be ineffective for the prevention of BMs in high-risk localised PCa patients at 4 yr.

PATIENT SUMMARY

Zoledronic acid administered every 3 mo was demonstrated to be ineffective for the prevention of bone metastases in high-risk nonmetastatic PCa patients at 4 yr.

TRIAL REGISTRATION

The ZEUS trial is registered in the Dutch trial register www.trialregister.nl and the ISRCTN register at http://www.controlled-trials.com/ISRCTN66626762.

Unmet needs in the prediction and detection of metastases in prostate cancer

The therapeutic landscape for the treatment of advanced prostate cancer is rapidly evolving, especially for those patients with metastatic castration-resistant prostate cancer (CPRC). Despite advances in therapy options, the diagnostic landscape has remained relatively static, with few guidelines or reviews addressing the optimal timing or methodology for the radiographic detection of metastatic disease. Given recent reports indicating a substantial proportion of patients with CRPC thought to be nonmetastatic (M0) are in fact metastatic (M1), there is now a clear opportunity and need for improvement in detection practices. Herein, we discuss the current status of predicting the presence of metastatic disease, with a particular emphasis on the detection of the M0 to M1 transition. In addition, we review current data on newer imaging technologies that are changing the way metastases are detected. Whether earlier detection of metastatic disease will ultimately improve patient outcomes is unknown, but given that the therapeutic options for those with metastatic and nonmetastatic CPRC vary, there are considerable implications of how and when metastases are detected.

Clostridium perfringens hip arthritis in a haemodialysis patient

Haemodialysis patients have acquired immunity disturbances, co-morbidities and a vascular access, factors predisposing them to infection and bacteraemia. Clostridium perfringens is an anaerobic bacterium potentially causing severe infections, including rarely septic arthritis. We report the first case of Clostridium perfringens septic arthritis in a haemodialysis patient and suggest a haematogenous spread. After rapid joint lavage combined with appropriate anti-microbial therapy, the patient recovered.

Modern Detection of Prostate Cancer's Bone Metastasis: Is the Bone Scan Era Over?

Prostate cancer cells have an exquisite tropism for bone, which clinically translates into the highest rate of bone metastases amongst male cancers. Although in the latest years there has been an active development of new "bone targeted" therapies, modern diagnostic techniques for bone metastases still relies mostly on (99m)Tc bone scanning (BS) and plain X-ray. BS dramatically lacks specificity and sensitivity. Recent publications using modern imaging technologies have clearly pinpointed that BS grossly underestimates the true prevalence of bone metastasis. In addition BS does not allow tumour measurement and is, therefore, not appropriate to monitor response to therapy. This might be extremely important in patients harbouring high-risk localized disease that are eventually candidate for local therapy. Here we reviewed what are the emerging imaging strategies that are likely to supplant BS and to what extent they can be used in the clinic already.

[Transient bone marrow edema of the hip]

Transient bone marrow edema of the hip is characterized by moderate homogeneous low MR signal intensity with ill-defined margins that involves at least a portion of the femoral head. Spin echo T1-weighted images are helpful to exclude other underlying diseases (tumor, infection, necrosis from systemic origin…), for which marrow edema is secondary or no epiphyseal in location. High-resolution fat-suppressed T2-weighted or proton density images allow evaluation of the articular cartilage, subchondral bone and subchondal marrow: if the articular cartilage is abnormal, the lesion is irreversible (arthrosis or necrosis); if the subchondral bone is focally interrupted and/or if the femoral is no longer spherical, the lesion is irreversible (necrosis); if a focal linear fluid collection is present under the subchondral bone, the lesion is irreversible (necrosis). Finally, subchondral changes may provide useful prognostic information: the absence of any abnormality other than marrow edema typically indicates that complete resolution is likely; the presence of a focal T2-weighted hypointense lesion immediately next to the subchondral bone suggests an irreversible lesion, especially if it is equal to or thicker than 4mm or the joint space. In some instances, prognosis cannot be reliably determined requiring the need for follow-up imaging.

[Tarsal osteoarthritis: a rare localisation of tuberculosis]

We report the case of a 39-year-old woman with an uneventful medical history who presented an inflammatory left foot with no notion of trauma or fever. The plain x-ray and magnetic resonance imaging demonstrated talonavicular and subtalar osteoarthritis. A surgical biopsy with excision of inflammatory and necrotic tissue and removal of a fistular tract was performed. Histology revealed the presence of granulomas with caseous central necrosis suggesting tuberculosis of the bone. The diagnosis was confirmed when bacteriology samples grew Mycobacterium tuberculosis. Antituberculosis drugs were administered for twelve months. At 24 months, the patient presents a painful stiff rear foot after the development of secondary talonavicular degeneration. This case illustrates a particular clinical presentation of tuberculosis. This diagnosis should be considered in the presence of atypical bony lesions with a chronic course. Early diagnosis enables proper therapeutic management. Useful diagnostic imaging techniques include plain x-rays, computed tomography, and magnetic resonance imaging. Certain diagnosis is based on bacteriological and histological examinations.

[Principles of analysis for sacroiliac joints imaging]

Interpretation of sacroiliac joints imaging is uneasy. Simultaneous erosions, hyperostosis, and ankylosis together make the diagnosis of inflammatory lesions. Articular abnormalities may also be induced by mechanical stress or ligament ossifications. Distribution of the lesions can help to establish a precise diagnosis. Inflammatory lesions may be located in any part of the articulation, including the posterior and inferior part. Mechanical lesions as in osteitis condensans ilii are commonly located in the anterior middle part of the joint. Ligament ossification in case of idiopathic skeletal hyperostosis is located at the margins of joint. The basic for the interpretation of sacroiliac joints is to look at high quality plain radiographs. When diagnosis is uncertain, complementary methods must be considered. CT is useful for analysis of subacute or chronic lesions and MRI is to be preferred for acute lesions, in young patients and when searching for signs of inflammatory activity in an already known chronic disease.

Bone marrow edema of the femoral head

This article addresses the MR features of the bone marrow edema syndrome (BMES) of the femoral head with emphasis on the prevalence and clinicopathology of the disorder and description of the current concepts on diagnosis and prognosis. BMES can be observed in self resolving conditions such as transient osteoporosis of the hip, spontaneous fracture of the femoral head, or post traumatic lesions. Rapidly destructive coxarthrosis, necrosis of the femoral head as well as certain forms of spontaneous fracture of the femoral head may present a similar MR pattern, though prognosis is definitely less favourable. The challenging role of the radiologist is to recognize BMES at an early stage and to provide adequate prognosis on the lesion outcome.

Proceedings of the SRBR-KBVR osteoarticular section meeting of March 27, 2004 in Leuven--part two. Spinal MR imaging in oncology

The objectives of the present review are to understand the value and limits of spinal marrow MR imaging in oncology, to present MR imaging protocols and elementary lesion patterns at MR imaging, and to emphasize indications for marrow MR imaging in clinical practice.

[Subacute osteomyelitis of the acetabulum]

A 15-months-old girl presented an excentration of the hip associated with a defect image of the acetabulum. Arthrography revealed a communication between the hip joint and the acetabular defect. Bacteriological specimens of the articular fluid were negative. The radiographic images were compatible with subacute osteomyelitis. Relative immobilization using an Atlanta abduction devise was undertaken. No medical treatment was prescribed for this adolescent who had received antibiotics for polymicrobial urinary tract infections and for pharyngitis prior to detection of the orthopedic disorder. Outcome was satisfactory with progressive filling of the acetabular defect but also with development of a subluxating coxa valga which required varus osteotomy of the femur. This case appears to illustrate a particular form of subacute osteomyelitis which is not described in earlier classifications.

Myxofibrosarcome intra-articulaire de la hanche chez un enfant de 10 ans

We report a case of intra-articular myxofibrosarcoma with acetabular involvement observed in a 10-Year-old boy. Myxofibrosarcoma is a frequent soft tIssue sarcoma usually observed in elderly subjects. It is extremely rare in children and has not been reported previously before the age of 22 Years. Myxofibrosarcoma is a specific type of soft tIssue tumor. Discussion continues concerning its relation with the myxoid variant of malignant fibrous histiocytoma. The myxoid matrix harbors fibroblastic cells with a curvilinear vessel configuration. Prognosis is good after complete resection and careful surveillance. Local recurrence may occur generally with progression of the tumor stage and risk of later metastasis. This is the first report of an intra-articular localization. We discuss the therapeutic options.

[Atypical ganglion cysts]

Intra- or para-articular ganglion cysts are frequent and can develop at some distance from the joints. The authors describe examples of typical and atypical ganglion cysts, namely meniscal cyst, intra-articular cyst, intraosseous cyst, intraneural cyst of tibial nerve, adventitial cyst of popliteal artery, and para-articular cyst of the hip, filled with gas of presumed articular origin. The diagnosis of a ganglion cyst can be difficult when there is no evident articular communication. If demonstration of communication is necessary (in case of uncertain diagnosis or for preoperative assessment), the best procedure is arthrography followed by a CT scan 1-2 hours after the injection.

[Myositis ossificans and other ossifying lesions of the soft tissues]

Knowledge of the clinical history and typical imaging characteristics of myositis ossificans is important as identification of this entity will avoid unnecessary and invasive work-up. Conversely, the radiologist must pay attention to any atypical clinical or imaging finding, which will warrant further investigations.

Complex karyotype and absence of mutation in the c-kit receptor in aggressive mastocytosis presenting with pelvic osteolysis, eosinophilia and brain damage

Aggressive mastocytosis is a form of systemic mast cell disease (SMCD) characterized by organ infiltration, bone lesions. eosinophilia and lymphadenopathies. Here we report a patient with unusual clinical features, namely osteolysis without other bone lesions commonly found in SMCD, major eosinophilia and cerebral infarction. The mast cells exhibited a classical immunophenotype (CD2+, CD9+, CD13+, CD25+, CD35+, CD45c+ and CD117+). Cytogenetic investigation showed novel complex aberrations, and clonal evolution was correlated with clinical progression. The screening for recurrent point mutations affecting the c-kit gene was negative. Mainly, the ASP816VAL substitution was not detected in our patient. Treatment with steroids and interferon was only temporarily effective.