Carney complex: Clinical and genetic 2010 update

First described in the mid 1980s, Carney complex is a rare dominantly heritable multiple endocrine neoplasia syndrome that affects endocrine glands as the adrenal cortex, the pituitary and the thyroid. It is associated with many other nonendocrine tumors, including cardiac myxomas, testicular tumors, melanotic schwannoma, breast myxomatosis, and abnormal pigmentation or myxomas of the skin. The Carney complex gene 1 was identified 10 years ago as the regulatory subunit 1A of protein kinase A (PRKAR1A) located at 17q22-24. An inactivating heterozygous germ line mutation of PRKAR1A is observed in about two-thirds of Carney complex patients. This last decade many progresses have been done in the knowledge of this rare disease and its genetics. This review outlines the current state of this knowledge on Carney complex.

Delayed-enhanced cardiac magnetic resonance imaging features in peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare disorder in which left ventricular systolic dysfunction and symptoms of heart failure occur in the peripartum period. Although cardiac magnetic resonance (CMR) is largely used for diagnosis and prognosis assessment in cardiomyopathies, its interest in PPCM is unknown. We reported two cases of patients with PPCM who underwent CMR. One patient had no CMR abnormality, while the second patient had several areas of myocardial delayed enhancement (MDE) on CMR images. During follow up, the patient with normal CMR was asymptomatic and had full recovery of cardiac function, whereas the patient with MDE was still symptomatic with persistence of a left ventricular dysfunction. CMR could have prognosis value in PPCM as demonstrated in other cardiomyopathies.

Impact of cardiac magnetic resonance imaging for assessment of Churg-Strauss syndrome: a cross-sectional study in 20 patients

OBJECTIVE

To examine the diagnostic contributions of cardiac magnetic resonance imaging (CMRI) with delayed-enhancement (DE) in patients with Churg-Strauss syndrome (CSS).

METHODS

We consecutively recruited 14 men and 6 women (mean age: 50+/-14 years) with CSS (mean disease duration: 4.5+/-3.6 years) and investigated them independently of the presence/absence of cardiac manifestations. Cardiac manifestations included heart failure in 6 patients, angina pectoris in 1, isolated ECG abnormality in 1, and isolated echocardiography and ECG abnormalities in 1. T1-weighted sequences were recorded after gadolinium injection to study myocardial DE.

RESULTS

CMRI abnormalities were found in 13/20 patients, including all 9 patients with myocardial manifestations, and 4 of the 11 asymptomatic patients. DE was centromyocardial in 6 patients, subepicardial in 4, and subendocardial in 3. Most enhanced lesions were in the anteroseptal or lateral walls. Patients with myocardial symptoms and DE had higher transmyocardial wall DE scores (mean: 9.4 vs. 3.7, respectively; p=0.01) and lower left ventricular ejection fractions (mean: 42% vs. 59%; p=0.001) than asymptomatic patients with DE.

CONCLUSION

CMRI with DE enabled the detection of myocardial involvement in CSS patients with or without clinical symptoms. The clinical relevance of CMRI abnormalities in patients without clinical, echocardiographic and ECG signs of cardiac involvement remains unknown and needs to be evaluated in future studies. It seems premature to intensify treatment or to prescribe systematically steroids and cytotoxic agents based on the presence of isolated CMRI anomalies.

Reversible tumor metastases growth acceleration following bevacizumab interruption and surgical resection of metastases

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Background: The addition of bevacizumab (BV), an anti-VEGF monoclonal antibody with antiangiogenic activity, to cytotoxic chemotherapy (CH) improves survival in metastatic colorectal cancer patients (pts). Reversal of VEGF inhibition is associated with rapid vascular regrowth in tumors in vivo (M.R. Mancuso et al, J Clin Invest; 116(10): 2610–2621, 2006). In the clinical setting, the consequences of BV interruption are poorly documented, especially in interactions with the surgical resection of liver metastases. Methods: We describe the kinetics of tumor growth prior to, during, and after interruption of BV and under BV reintroduction, in consecutive colorectal cancer pts experiencing objective response under CH+BV, followed by surgical resection of metastases. We measured either clinically, of using CT-scan, the diameter of target lesions according to RECIST criteria, and the doubling time. Results: 7 pts (3 F, 4M), with median age of 54 years (41–70), were treated with 5-FU based CH (+oxaliplatin: 5; + irinotecan: 1 pt) and BV for metastatic colo- (6 pts) rectal (1 pt) cancer received a median number of 6 (4–18) cycles. Median time between BV interruption and surgery: 8 weeks (3–12). Under BV, all pts experienced objective response, with a median tumor reduction of 13%/month (extr: 6–15%). After BV interruption, under CH alone, 2/7 pts experienced disease progression, with a tumor growth of the residual disease of +7% and +200%/month, respectively. In pts who underwent surgery, during the off therapy period, tumor growth occurred in all 7 pts with a kinetics of +17 to +400%/month. Tumor growth doubling time after BV interruption ranged between 2 and 5 weeks. Reintroduction of BV re-induced a tumor response in 5/7 pts with a median time to response of 8 weeks (6–12) and a reduction of 10%/month. Conclusions: We show reproducible evidence of tumor growth acceleration following BV interruption. Surgery might transiently modify the balance between angiogenic and anti-angiogenic factors. We suggest to reduce the duration of BV interruption and to restart BV as soon as possible after surgery. These observations justify a large prospective analysis of the variations of tumor growth in this setting.

No significant financial relationships to disclose.

[The contribution of computed tomography coronary angiography in Kawasaki disease in adult patients. Report of two cases]

OBJECTIVES

During the past few years, multislice computed tomography coronary angiography has made great progress in terms of spatial and temporal resolution. Results on detection and quantification of stenoses are excellent. We found interesting reporting its achievements in aneurismal coronaropathies such as the Kawasaki disease.

METHODS

We searched for young adults with Kawasaki disease who had a multislice computed tomography coronary angiography available. Several hospitals in the Paris area have been contacted and only two observations have been kept.

RESULTS

Computed tomography provided higher performance than coronarography for the measurement of the real diameter of an aneurism taking into account the mural thrombus, evaluation of its links with the collateral branches and the other aneurisms, assessment of the development of recanalized vessels and the degree of development of collateral vessels, and visualization of non-circulating aneurisms which were not detected with coronary angiography. In addition, the evaluation of the location and the degree of the stenoses by the computed tomography matched the coronary angiography data. It was not possible to conclude with this observations that the computed tomography is better for the diagnostic of Kawasaki disease.

CONCLUSION

Multislice computed tomography coronary angiography will be likely more and more used to detect and follow coronary anomalies in case of Kawasaki disease among teenagers and young adults. It is recommended for monitoring medium or large aneurisms in order to evaluate their progression to stenosis.

[Radiologically-guided hysterosalpingography and tubal catheterization]

Radiological exploration of hypofertility by means of hysterosalpingography is a method still valid but no longer sufficient. Tubal catheterization has thus become a necessary complementary exam in order to eliminate the pseudo-obturations of hysterosalpingography and, in case of proximal tubal obstructions, to obtain pregnancies. The conditions for the realization of hysteroalpingography and tubal catheterization are hereby described, with emphasis on the rigorous technique that is required together with careful listening to the patients.

[Coronary artery implantation and course abnormalities: the contribution of multislice CT]

Abnormalities in coronary artery origin and course are rare and often asymptomatic. However, visualizing them is of great interest because they can be responsible for iatrogenic trauma during cardiac surgery, and, for some of them, for myocardial infarction, which can lead to sudden death. We show the contribution of multislice CT in the positive diagnosis of these anatomic variations and in the differential diagnosis between benign and malignant forms, potentially responsible for myocardial ischemia.

[Large coronary aneurysm diagnosed during an acute coronary syndrome. A case report and review of the literature]

Coronary aneurysm is an uncommon variant of coronary atherosclerosis. It usually involves the right coronary artery and is often associated with significant coronary stenosis. It may be revealed by an acute coronary syndrome (ACS). We report the case of a 49 year-old woman in whom a large coronary aneurysm of the left anterior descending artery was revealed by an ACS. Coronary angiography remains the gold standard diagnosis procedure, but spiral computed tomography may be of interest to specify the location and nature of the aneurysm, and thus guide surgical or percutaneous treatment.

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

BACKGROUND

Cardiac involvement in idiopathic inflammatory myopathy has been recognised as an important prognostic factor, but treatment remains empirical.

OBJECTIVE

To investigate the effects of corticosteroids and immunosuppressors on myocarditis in patients with inflammatory myopathies.

METHODS

Patients with inflammatory myositis of recent onset who had not received treatment were evaluated for associated myocarditis by magnetic resonance imaging (MRI) and reinvestigated after treatment with high dose corticosteroids and immunosuppressors.

RESULTS

Four patients with histologically proven myositis were included. Two patients with polymyositis had cardiac clinical symptoms. Two other patients with dermatomyositis and diffuse cutaneous systemic sclerosis-polymyositis overlap syndrome were asymptomatic. In three cases the usual conventional screening tests were normal. For all patients an area of contrast enhancement and hypokinesia detected by cardiac MRI was markedly reduced after treatment with corticosteroids and immunosuppressors for 6 months.

CONCLUSION

Treatment with intravenous methylprednisolone followed by prednisone and immunosuppressive therapy seems to be effective for treating myocardial involvement in patients with idiopathic inflammatory myopathies, either alone or presenting as overlap syndromes. Cardiovascular MRI is a non-invasive technique that may be a powerful tool for diagnosis and monitoring of myocardial inflammation in this setting.

Cardiac gas embolism after central venous catheter removal

Clinical images reporting intracardiac gas level are sparce and, to our knowledge, the presence of gas embolism into the coronary arteries has never been reported. We describe the case of a young man who experiences life-threatening gas embolism with the presence of gas bubbles into cardiac cavities and coronary arteries.

Evaluation of the effect of nifedipine upon myocardial perfusion and contractility using cardiac magnetic resonance imaging and tissue Doppler echocardiography in systemic sclerosis

BACKGROUND

Primary myocardial involvement due to microcirculation impairment is common in systemic sclerosis (SSc). Cardiovascular magnetic resonance imaging (MRI) and tissue Doppler echocardiography (TDE) were recently shown to be more sensitive than conventional methods for the respective assessment of myocardial perfusion and contractility. Previous studies have suggested that dihydropyridine-type calcium channel blockers mitigate both myocardial perfusion and function abnormalities.

OBJECTIVE

To investigate the effects of nifedipine on myocardial perfusion by MRI and on contractility by TDE, in patients with SSc.

PATIENTS AND METHODS

18 patients with SSc without clinical heart failure and with normal pulmonary arterial pressure (14 women, 4 men; mean (SD) age 59 (9) years; mean (SD) disease duration 7 (4) years, 10 with diffuse and 8 with limited cutaneous forms) were prospectively evaluated. The MRI perfusion index, determined from time-intensity curves, and systolic and diastolic strain rate determined by TDE were assessed at baseline, after a 72 hour vasodilator washout period, and after 14 days of oral treatment with nifedipine 60 mg/day.

RESULTS

Nifedipine treatment led to a significant increase in the MRI perfusion index (mean (SD) 0.26 (0.07) v 0.19 (0.05) at baseline, p = 0.0003) and in systolic and diastolic strain rate (2.3 (0.6) v 1.5 (0.4) s(-1) at baseline, p = 0.0002, and 4.2 (1.6) v 3.0 (1.2) at baseline, p = 0.0003, respectively).

CONCLUSION

Fourteen days of treatment with nifedipine simultaneously improves myocardial perfusion and function, as evaluated by highly sensitive and quantitative methods.

Apport de l’IRM dans l’exploration des anomalies cardiaques congénitales et des gros vaisseaux

Management of congenital heart diseases (CHD) frequently is a diagnostic challenge. MRI, as a complement to echocardiography, plays an important role in the non-invasive evaluation of these anomalies. MRI allows high resolution anatomical evaluation of these structures in multiple planes as well as functional evaluation. These features are helpful to further characterize extra-cardiac anomalies that may be difficult to assess at US and even angiography. MRI is thus a valuable imaging tool in the evaluation of CHD.

Maladie coronaire : les questions cliniques et les réponses potentielles en scanner multicoupe et en IRM

If the role of multislice CT and MRI is not clearly defined in ischemic heart disease, these new cardiac imaging techniques are very promising due to recent technological advances. The detection of coronary artery plaque and stenosis, as well as coronary bypass graft and stenting patency, the evaluation of left ventricular remodeling after infarction, are available in routine with a 16-slices multislice CT. MRI is the technique of choice to appreciate the impact of a coronary artery lesion on myocardium: detection of ischemia by first-pass perfusion imaging at rest and under pharmacological stress, detection and extension of infarcted myocardium and assessment of myocardial viability. The potential indications will be discussed for each technique in the light of the main clinical questions asked by the cardiologist in daily practice.

[Cardiomyopathies]

Cardiomyopathies include a wide variety of cardiac diseases. The value of MR imaging is not only to provide information about cardiac function, but also to detect the underlying cause of the disease.

[Anomalies of myocardial contractility: CT and MR appearance]

Cardiac output relies on an appropriate contractile function. It is mandatory to recognize kinetic alterations of the myocardium and to precise their extent (i.e. segmental, regional or global), to quantify their consequences on the function of the cardiac pump, and to assess if the underlying disease is reversible or fixed.

Video-assisted thoracoscopic surgery as a first-line treatment for mediastinal parathyroid adenomas: strategic value of imaging

OBJECTIVE

To present first-line thoracic surgery made possible by localization studies in three patients with ectopic parathyroid adenomas.

DESIGN AND METHODS

Three patients with ectopic parathyroid tissue in the mediastinum were examined by ultrasound, technetium-99m sestamibi scintigraphy, computed tomography (CT), and venous catheterization with measurement of parathyroid hormone. Without previous cervical exploration, video-assisted thoracic surgery (VATS) was used in all cases to avoid the need for thoracic open surgical procedures.

RESULTS AND CONCLUSIONS

The mediastinal parathyroid glands were all detected at scintigraphy, and CT and venous catheterization were helpful in anatomic and functioning characterization. All pathologic glands were successfully resected, with only one minor complication. VATS can safely remove a deep mediastinal parathyroid adenoma and avoid more aggressive open approaches. In an experienced referral center, systematic and sophisticated imaging studies may accurately identify and localize rare ectopic parathyroid adenomas, and avoid cervical surgery.

[Diagnosis of ectopic mediastinal parathyroid adenomas: value of cardiac MRI]

Primary hyperparathyroidism is due to an adenoma in 85% of cases. In 10% of cases, the parathyroid adenoma may be in an ectopic location. Ten per cent of these ectopic adenomas are located in the mediastinum. Imaging modalities performed in persistent or recurrent hyperparathyroidism include ultrasound, MIBI scintigraphy, venous blood sampling, helical CT and MRI. The authors report 3 cases of ectopic adenoma located in the mediastinum, where pre-operative diagnosis was confirmed using cardiac MRI sequences.

Hepatofugal portal flow in advanced liver cirrhosis with spontaneous portosystemic shunts: effects on parenchymal hepatic enhancement at dual-phase helical CT

BACKGROUND

We investigated whether spontaneous hepatofugal portal flow in advanced cirrhosis affects hepatic enhancement on dual-phase helical computed tomography.

METHODS

Fifteen patients with hepatofugal portal flow on Doppler sonography and angiography (group 1) and 15 age- and sex-matched patients with hepatopetal portal flow (control; group 2) underwent dual-phase helical computed tomography. Vascular and liver attenuation values were measured on unenhanced scans and scans obtained during hepatic arterial (HAP; 25 s) and portal venous (PVP; 70 s) phases.

RESULTS

Portal vein enhancement was lower during PVP in group 1 than in group 2 ( p < 0.0001). Liver enhancement was higher during HAP and lower and delayed during PVP in group 1 versus group 2 ( p < 0.0001).

CONCLUSION

In hepatofugal portal flow, liver enhancement is increased during HAP and compensating for decreased and delayed liver enhancement during PVP, resulting in potential decreased hypervascular tumor conspicuity.

Hepatic and vascular enhancement at dual-phase helical CT: comparison of Iobitridol 300 and Iohexol 300 in a prospective randomized study

The purpose of this study was to determine hepatic and vascular enhancement, clinical tolerance, and iconographic quality of Iobitridol (300 mg/ml) at dual-phase helical CT and to compare it with Iohexol (300 mg/ml). One hundred forty-six patients were randomly divided into two groups. Each group received 120 ml of Iohexol (group A) or Iobitridol (group B). Mean enhancement of liver, aorta and portal vein was obtained at the arterial phase and at the portal-venous phase. Overall image quality was assessed by two independent blinded investigators. Adverse reactions were recorded. There were no significant differences in demographic characteristics and distribution of patient intrinsic parameters between the two groups, except for blood pressure but without statistical correlation between the difference in blood pressure and the impact on enhancement measurements. There was no significant difference in clinical tolerance and image quality. Mean liver as well as aortic and portal vein enhancement measurements did not show any significant difference. Iobitridol compares favorably with Iohexol. Both products have similar safety, tolerance, and efficacy. Both contrast media have equivalent blood pool concentration and interstitial compartment diffusion.

Peliosis hepatis: triphasic helical CT and dynamic MRI findings

We report the triphasic helical computed tomographic (CT) and dynamic magnetic resonance imaging (MRI) findings in a unique case of biopsy-proven peliosis of the liver. Several reports have described the CT and MRI findings of this entity without specific appearance. This report discusses the usefulness of dynamic helical CT and MRI for the early diagnosis of peliosis.

Cirrhotic liver enhancement on dual-phase helical CT: comparison with noncirrhotic livers in 146 patients

OBJECTIVE

The purpose of this study was to prospectively determine any differences in vascular and liver enhancement between patients with cirrhosis and patients without cirrhosis during both the arterial and portal venous phases on dual-phase helical CT.

SUBJECTS AND METHODS

Fifty-eight patients with histologically proven cirrhosis (group 1) and 88 without cirrhosis (group 2 = normal findings on CT, group 3 = metastases, group 4 = other liver diseases) underwent dual-phase helical CT of the liver. Attenuation values of liver and vessels were measured on unenhanced scans and on scans obtained during the arterial and portal venous phases. The mean enhancement values per time interval (5 sec) were determined. Results were analyzed taking into account various intrinsic patient parameters.

RESULTS

We found no statistically significant difference in terms of mean vascular enhancement and mean liver enhancement during the arterial imaging phase for each time interval among all the groups. The mean peak enhancement and mean liver enhancement during the portal venous phase were significantly lower in group 1 than in other groups. Time to peak enhancement was significantly delayed in group 1.

CONCLUSION

In spite of the hepatic arterial buffer response, mean liver enhancement during the arterial phase was not significantly different in patients with cirrhosis compared with patients without cirrhosis. Although portal vein enhancement did not differ significantly, enhancement of cirrhotic liver was significantly lower during the portal venous phase and delayed, presumably because of decreased peripheral portal perfusion. The contrast injection protocol may be tailored to optimize conspicuity of hypovascular tumor.

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

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

Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography

OBJECTIVE

The purpose of this study was to compare dual-phase helical CT and endosonography for the diagnosis and staging of pancreatic tumors.

SUBJECTS AND METHODS

Thirty patients with suspected pancreatic tumors underwent endosonography and dual-phase helical CT. A pathologic diagnosis was obtained in all cases with surgery (n = 23) or biopsy (n = 7), resulting in 27 neoplasms. Dual-phase helical CT and endosonographic findings were correlated with surgical and pathologic findings to determine diagnosis and resectability of pancreatic tumors.

RESULTS

Overall diagnostic sensitivity was 92% for dual-phase helical CT and 100% for endosonography (p = .45). Overall accuracy for staging of pancreatic tumors was 93% for both dual-phase helical CT and endosonography. Overall accuracy for predicting resectability was 90% for both dual-phase helical CT and endosonography. Accuracy of predicting unresectability was 100% for dual-phase helical CT and 86% for endosonography (p > .80). Differences were not considered statistically significant.

CONCLUSION

Dual-phase helical CT and endoscopic sonography do not differ significantly for diagnosis and assessment of resectability of pancreatic tumors.

[Hypersignal of the intervertebral disks in T1-weighted spin-echo MRI sequences]

In magnetic resonance imaging, when there is calcification of the intervertebral disk, signals usually become weaker in all the sequences. Exceptionally, a spontaneous hypersignal is obtained in T1 weighted spin-echo sequences. We report 4 cases of spontaneous hypersignals from disks in T1 weighted spin-echo sequences. In 3 cases, calcifications were visualized with conventional radiology or computed tomography. In 1 case, there was no calcification of the disk, but its density, compared with adjacent disks, was 20 HU greater, suggesting inframacroscopic calcification.