MR Features of Juxta-Articular Venous Malformations of the Knee to Predict the Clinical Outcome of Sclerotherapy

PurposeTo analyze and correlate preinterventional magnetic resonance (MR) imaging findings with clinical symptoms after percutaneous sclerotherapy of venous malformations (VMs) adjacent to the knee.Materials and MethodsTwenty-five patients (mean age, 24 y; range, 7–55 y; 11 female) with 26 VMs adjacent to the knee undergoing sclerotherapy (direct puncture, diagnostic angiography, sclerosant injection) were identified, and MR imaging findings were analyzed. The VM involved the synovium of the knee joint in 19 of 26 cases (76%). These lesions were associated with joint effusion (3 of 19; 16%), hemarthrosis (4 of 19; 21%), or synovial thickening (16 of 19; 84%). Follow-up ended 6–8 weeks after the first or second sclerotherapy session if complete pain relief was achieved or 3 months after the third sclerotherapy session. Treatment outcomes were categorized as symptom improvement (complete or partial pain relief) or poor response (unchanged or increased pain).ResultsForty-nine percutaneous sclerotherapy sessions were performed. Despite the absence of signs of knee osteoarthritis, patients with a VM involving the synovium (8 of 14; 57%) showed a poor response to sclerotherapy (1 of 8 [13%] pain-free after 1 sclerotherapy session). Among patients with VMs with no associated joint alteration and no synovial involvement (6 of 14; 43%), 5 of 6 (83%) showed improvement of symptoms after 1 sclerotherapy session (P < .05).ConclusionsJuxta-articular VMs of the knee are frequently associated with hemarthrosis and synovial thickening. Patients with signs of osteoarthritis and synovial involvement of the VM on presclerotherapy MR imaging deserve special consideration, as these findings predict worse clinical symptoms after sclerotherapy.     

Clinical outcome and predictors of treatment response in foam sodium tetradecyl sulfate sclerotherapy of venous malformations

Objectives

To evaluate clinical outcomes and their predictors in patients with venous malformation (VM) treated with foam sodium tetradecyl sulfate (STS) sclerotherapy.

Methods

We retrospectively evaluated clinical outcomes of foam STS sclerotherapy in 86 patients with 91 VMs to assess reduction in pain and mass after treatment. Univariate and multivariate analysis was performed to determine possible predictors of clinical outcome with foam STS sclerotherapy.

Results

A positive response of 49.5 % in pain reduction and 52.7 % in mass reduction was observed. The numerical rating scale (NRS) score improved from 4.36?±?2.64 to 1.74?±?1.57, and VM mass volume decreased to 41.7?±?35.52 % of the initial size. On multivariate analysis, a high baseline NRS score (odds ratio: 1.12, 95 % confidence interval: 1.09–1.15) and VM location in the trunk versus the head and neck (odds ratio: 1.30, 95 % confidence interval: 1.00–1.69) were positive predictors of pain improvement. Minor complications occurred in 11 (12.1 %) patients and recurrence in 12 (13.2 %) patients.

Conclusions

Foam STS sclerotherapy is an effective treatment in venous malformation, with low complication risk. A high baseline NRS score and location in the trunk versus the head and neck were positive predictors in improvement of pain.

Key Points

? Foam STS sclerotherapy is effective in VM, with low risk of complications. ? Relief of pain tends to be dramatic in patients with severe pain. ? Location of VM is a predictor of pain improvement. ? The presence of a draining vein does not affect foam sclerotherapy.

     

Cementoplasty for managing painful bone metastases outside the spine

Objective

To illustrate the effect of treatment with cementoplasty in patients with painful bone metastases in the extraspinal region.

Methods

A retrospective study was conducted to review 51 consecutive patients who underwent cementoplasty under CT or fluoroscopic guidance, a total of 65 lesions involving the ilium, ischium, pubis, acetabulum, humeral, femur and tibia. In 5 patients with a high risk of impending fracture in long bones based on Mirels’ scoring system, an innovative technique using a cement-filled catheter was applied. The clinical effects were evaluated using the visual analogue scale (VAS) preoperatively and postoperatively.

Results

All patients were treated successfully with a satisfying resolution of painful symptoms at 3 months’ follow-up. Cement leakage was found in 8 lesions without any symptoms. VAS scores decreased from 8.19?±?1.1 preoperatively to 4.94?±?1.6 at 3 days, 3.41?±?2.1 at 1 month and 3.02?±?1.9 at 3 months postoperatively. There was a significant difference between the mean preoperative baseline score and the mean score at all of the postoperative follow-up points (P?<?0.01).

Conclusions

Cementoplasty is an effective technique for treating painful bone metastases in extraspinal regions, which is a valuable, minimally invasive, method that allows reduction of pain and improvement of patients’ quality of life.

Key Points

? Metastases in long bones may cause pain and subsequent pathological fractures. ? Cement-filled catheter resulted in a fixation effect to prevent pathological fractures. ? Cementoplasty resulted in significant pain relief in patients with extraspinal metastases.     

Benign painful shoulder syndrome

Background and purpose

To compare the efficacy of two different dose-fractionation schedules for radiotherapy of patients with benign painful shoulder syndrome.

Patients and methods

Between February 2006 and February 2010, 312 consecutive evaluable patients were recruited for this prospective randomized trial. All patients received radiotherapy with an orthovoltage technique. One radiotherapy course consisted of 6 single fractions in 3?weeks. In case of insufficient remission of pain after 6?weeks, a second radiation series was performed. Patients were randomly assigned to receive either single doses of 0.5 or 1.0?Gy. The endpoint was pain reduction. Pain was measured before, right after, and 6?weeks after radiotherapy using a visual analogue scale (VAS) and a comprehensive pain score (CPS).

Results

The overall response rate for all patients was 83% directly after and 85% 6?weeks after radiotherapy. The mean VAS values before, directly after, and 6?weeks after treatment for the 0.5 and 1.0?Gy groups were 56.8?±?23.7 and 53.2?±?21.8 (p?=?0.158), 38.2?±?26.1 and 34.0?±?24.5 (p?=?0.189), and 33.0?±?27.2 and 23.7?±?22.7 (p?=?0.044), respectively. The mean CPS before, directly after, and 6?weeks after treatment was 9.7?±?3.0 and 9.5?±?2.7 (p?=?0.309), 6.1?±?3.6 and 5.4?±?3.6 (p?=?0.096), 5.3?±?3.7 and 4.1?±?3.7 (p?=?0.052), respectively. Despite a slight advantage in the VAS analysis for the 1.0?Gy group for delayed response, the CPS analysis revealed no statistically significant differences between the two single-dose trial arms for early (p?=?0.652) and delayed response quality (p?=?0.380).

Conclusion

Radiotherapy is an effective treatment option for the management of benign painful shoulder syndrome. Concerning radiation protection, the dose for a radiotherapy series is recommended not to exceed 3?C6?Gy.     

Radiosynoviorthesis in hemophilic arthropathy: pathologic blood pool imaging on pre-therapeutic bone scintigraphy is not a predictor of treatment success

Purpose

Increased articular ^99mTc MDP uptake on blood pool imaging (BPI) of patients with rheumatologic conditions is indicative of active inflammatory changes, and has been suggested as a strong predictor of response to radiosynoviorthesis (RSO). In this study, we aimed to assess the value of pretreatment BPI positivity (i.e. scintigraphic-apparent hyperemia) for successful RSO in hemophilic arthropathy.

Methods

Thirty-four male patients with painful hemophilic arthropathy underwent RSO after failure of conservative treatment. Treated joints comprised the knee in eight, elbow in five, and ankle in 21 patients. Pretreatment triple-phase bone scintigraphy showed hyperemic joints (pathologic BPI) in 17 patients, whereas 17 patients had no increased tracer uptake on BPI. Response to RSO was evaluated 6 months post-treatment by measuring changes in intensity of arthralgia according to the visual analog scale (VAS), bleeding frequency, and range of motion. The association between hyperemia (pathologic BPI) and treatment outcome was examined using nonparametric tests for independent samples.

Results

Clinically evident pain relief occurred in 26 patients (76.5 %), and the mean VAS decreased from 7.7?±?1.1 to 4.6?±?2.7 (p?<?0.001). Joint bleeding frequency (hemarthrosis) decreased from 4.5?±?0.6 to 2.1?±?0.4 during the first 6 months after RSO (p?<?0.001). For both parameters (pain relief and bleeding frequency), patients experienced a similar benefit from RSO regardless of pretreatment BPI: arthralgia (p?=?0.312) and frequency of hemarthrosis (p?=?0.396). No significant improvement was observed for range of motion, but it was significantly more restricted in hyperemic joints both before (p?=?0.036) and after treatment (p?=?0.022).

Conclusions

Hemophilic arthropathy can be effectively treated with RSO regardless of pre-therapeutic BPI. Patients in whom articular hyperemia is not detectable by scintigraphy may have similar (outstanding) outcomes, and thus should not be excluded from treatment.

     

Radio-opaque ethylcellulose-ethanol is a safe and efficient sclerosing agent for venous malformations

Objective

To evaluate the efficacy and safety of gelified ethanol, a newly developed sclerosing agent for slow-flow vascular malformations.

Methods

Seventy-nine sclerotherapy procedures were performed on 44 patients with 37 venous malformations, 2 glomuvenous malformations, 2 lymphatic malformations, 2 lymphatico-venous malformations, and 1 Klippel-Trenaunay syndrome. The median injected volume was 1.00 mL/site of injection. Effects of sclerotherapy on pain, functional and cosmetic disturbance were statistically evaluated with a final result score. Local and systemic complications were recorded.

Results

The mean Visual Analogue Scores were 5.20?±?2.81 before and 1.52?±?1.25 after treatment (p?Conclusion Per mL used, radio-opaque gelified ethanol is at least as effective as absolute ethanol. No systemic complication was observed, as only a low dose of ethanol was injected. Indications for sclerotherapy can be widened to areas with higher risk for local side effects (hands and periocular region), as ethanol is trapped in the lesion. Careful injection procedure is though necessary, because only a limited amount of ethylcellulose can be used per puncture. Key Points ? Development of a new sclerosing agent for venous malformations. ? Interesting novel way to deliver alcohol to slow-flow vascular malformations. ? Alcohol-based with less local and systemic side-effects.     

Clinical validation of semi-automated software for volumetric and dynamic contrast enhancement analysis of soft tissue venous malformations on Magnetic Resonance Imaging examination

Objectives

To evaluate venous malformation (VM) volume and contrast-enhancement analysis on magnetic resonance imaging (MRI) compared with diameter evaluation.

Methods

Baseline MRI was undertaken in 44 patients, 20 of whom were followed by MRI after sclerotherapy. All patients underwent short-tau inversion recovery (STIR) acquisitions and dynamic contrast assessment. VM diameters in three orthogonal directions were measured to obtain the largest and mean diameters. Volumetric reconstruction of VM was generated from two orthogonal STIR sequences and fused with acquisitions after contrast medium injection. Reproducibility (interclass correlation coefficients [ICCs]) of diameter and volume measurements was estimated. VM size variations in diameter and volume after sclerotherapy and contrast enhancement before sclerotherapy were compared in patients with clinical success or failure.

Results

Inter-observer ICCs were similar for diameter and volume measurements at baseline and follow-up (range 0.87–0.99). Higher percentages of size reduction after sclerotherapy were observed with volume (32.6?±?30.7 %) than with diameter measurements (14.4?±?21.4 %; P?=?0.037). Contrast enhancement values were estimated at 65.3?±?27.5 % and 84?±?13 % in patients with clinical failure and success respectively (P?=?0.056).

Conclusions

Venous malformation volume was as reproducible as diameter measurement and more sensitive in detecting therapeutic responses. Patients with better clinical outcome tend to have stronger malformation enhancement.

Key points

? Magnetic resonance imaging readily demonstrates diameters and volumes of venous malformations ? MRI diameter calculations are reproducible in estimating the size of venous malformations ? But volumetric models of malformations are more sensitive in detecting therapeutic response ? Dynamic enhancement is also better assessed with automated volumetric software ? Volumetric analysis of malformations offers promise to guide therapy and assess response     

Percutaneous MR Imaging–Guided Laser Ablation for the Treatment of Symptomatic Cervicofacial Vascular Malformations

PurposeTo evaluate the safety and effectiveness of percutaneous magnetic resonance (MR) imaging–guided laser ablation for the treatment of symptomatic soft tissue vascular malformations (VMs) in the face and neck.Materials and MethodsAn institutional review board–approved retrospective review was undertaken of all consecutive patients who underwent MR imaging–guided and monitored laser ablation for treatment of symptomatic, cervicofacial soft tissue VM. Preablation and postablation MR imaging findings were independently reviewed. Preablation and postablation VM sizes were documented. Preablation T2 signal characteristics and enhancement patterns as well as postablation change in both signal and enhancement were semiquantitatively assessed. Changes in VM size were compared using a paired t test.ResultsThirteen patients (women, 9; age, 14.5–69.5 years) with 13 VMs were treated for moderate-to-severe pain (n = 4), swelling/mass effect (n = 8), or predominantly cosmesis (n = 1) with 22 total ablation sessions. The baseline maximum VM diameter was 5.7 cm ± 4.2. At baseline, all VMs (100%) demonstrated variable T2-weighted signal hyperintensity and enhancement. For painful VM, the baseline pain score was 8 ± 1. Clinical follow-up was available for 10 patients. Of patients with available follow-up, 3 (100%) treated for moderate-to-severe pain and 7 (100%) treated for swelling/mass effect reported subjective complete or partial symptomatic relief. The patient treated predominantly for cosmetic reasons was lost to follow-up. Two patients (15.4%) experienced minor adverse events by the Society of Interventional Radiology standards. There were no major adverse events.ConclusionsMR imaging–guided and monitored percutaneous laser ablation is safe and effective for the treatment of symptomatic, cervicofacial VMs.     

Combined Transarterial Embolization and Percutaneous Sclerotherapy as Treatment for Refractory and Nonresectable Aneurysmal Bone Cysts

PurposeTo evaluate the safety and effectiveness of combined transarterial embolization and percutaneous sclerotherapy in the treatment of refractory and nonresectable aneurysmal bone cysts (ABCs) as assessed by imaging and clinical outcomes.Materials and MethodsThis retrospective, single-center study included 16 consecutive patients (9 women and 7 men; median age, 17 years [range, 6–25 years]) who underwent combined transarterial embolization (using ethylene vinyl alcohol) and percutaneous sclerotherapy (using ethanol gel and polidocanol) for refractory and nonresectable ABCs. The median follow-up was 27.3 months (range, 6.7–47.5 months). Grade of mineralization (5-point Likert scale), grade of fluid-fluid levels (FFLs; 4-point Likert scale), and contrast-enhancing lesion volume were evaluated before and after treatment. The quality of life was determined before and after treatment using the Musculoskeletal Tumor Society (MSTS) score and the 36-Item Short Form Survey (SF-36) health questionnaire.ResultsA mean of 1.6 ± 0.7 transarterial embolizations and 3.2 ± 1.7 percutaneous sclerotherapies were performed. No adverse events were observed. All patients showed either partial or complete response; no patient showed ABC recurrence. The grade of mineralization (3.7 ± 0.7 after therapy vs 1.4 ± 0.5 at baseline; P < .0001) and grade of FFL (3.5 ± 0.8 after therapy vs 1.9 ± 0.6 at baseline; P < .0001) significantly improved after therapy compared with baseline. The mean contrast-enhancing lesion volume significantly decreased after treatment compared with baseline (45.9 mm³ ± 96.1 vs 156.0 mm³ ± 115.3, respectively; P = .0003). The MSTS scores (28.8 ± 1.8 after treatment vs 14.1 ± 8.6 at baseline; P < .0001) and SF-36 findings revealed a significant improvement in the quality of life after treatment compared with baseline, leaving most patients without relevant constraints.ConclusionsCombined transarterial embolization and percutaneous sclerotherapy is a minimally invasive, safe, and effective treatment option for refractory and nonresectable ABCs. Treatment fostered bone mineralization and significantly improved patients’ quality of life.     

2种硬化剂在单纯性肝肾囊肿硬化治疗中的对比研究

目的:对超声引导下单纯性肝肾囊肿穿刺注射新型硬化剂和无水乙醇治疗的疗效进行对比研究。方法:对32例患者36个肝肾囊肿(18例肝囊肿,14例18个肾囊肿)经超声引导抽净囊液后,注入适量新型硬化剂1%聚桂醇注射液(国药准字H20080445),并留置囊内,观察治疗过程中发生的不良反应、患者耐受程度,6月跟踪统计有效率;并与我院采用传统无水乙醇硬化剂治疗的肝肾囊肿统计数据进行对比。结果:32例36个囊肿均一次穿刺成功,按1/10～1/4的比例注入新型硬化剂并保留囊内,患者耐受性良好,无刺激性疼痛和醉酒症状,治疗后1周内,9例患者诉侧腹轻微胀痛,间断低热2 d,未经特殊处理自行消失,无严重不良反应。6月复查33例全部消失,3个囊肿缩小2/3以上,有效率达100%,长期疗效仍在跟踪中。采用传统无水乙醇作为硬化剂注射治疗肝肾囊肿20例(12例肝囊肿,8例肾囊肿),抽净囊液后,按1/4～1/3比例注入无水乙醇,注射时均有短暂刺激性疼痛,18例出现面红、心跳加快、口干、恶心呕吐等醉酒症状。6月复查15例完全消失,5例缩小2/3以上。结论:新型硬化剂聚桂醇治疗肝。肾囊肿疗效与传统无水乙醇硬化治疗一致,但它留置体内,无刺激性剧痛,无醉酒症状,操作简单,不良反应少,患者耐受性好,优于无水乙醇,有望在肝肾囊肿的硬化治疗中成为无水乙醇的替代物。     

MRI-guided percutaneous sclerotherapy of venous malformations: initial clinical experience using a 3T MRI system

PurposeVenous malformations (VMs) are low-flow vascular anomalies that are commonly treated with image-guided percutaneous sclerotherapy. Although many VMs can be safely accessed and treated using ultrasonography and fluoroscopy, some lesions may be better treated with magnetic resonance imaging (MRI)–guided sclerotherapy. The aim of this study is to evaluate the feasibility, efficiency, and outcomes of MRI-guided sclerotherapy of VMs using a 3T MRI system.MethodsSix patients with VMs in the neck (n = 2), chest (n = 1), and extremities (n = 3) underwent sclerotherapy with 3T MRI guidance. Feasibility was assessed by calculating the technical success rate and procedural efficiency. Efficiency was evaluated by using planning, targeting, intervention, and total procedure times. Outcomes were assessed by measuring VM volumes before and after sclerotherapy, patient-reported pain scores, and occurrence of complications.ResultsTechnical success was achieved in all 6 procedures. There was a non-significant 30% decrease in mean VM volume after the procedure (P = .350). The procedure resulted in a decrease in mean pain score (on an 11-point scale) of 2.6 points (P = .003). After the procedure, 4 patients reported complete pain resolution, 1 reported partial pain resolution, and 1 reported no change in pain. Procedural efficiency was consistent with similar sclerotherapy procedures performed at our institution. There were no major or minor complications.Conclusion3T MRI guidance is feasible for percutaneous sclerotherapy of VMs, with promising initial technical success rates, procedural efficiency, and therapeutic outcomes without complications.     

Value of percutaneous radiofrequency ablation with or without percutaneous vertebroplasty for pain relief and functional recovery in painful bone metastases

Objective

To evaluate the effectiveness of percutaneous radiofrequency (RF) ablation with or without percutaneous vertebroplasty (PV) on pain relief, functional recovery and local recurrence at 6?months?? follow-up (FU), in patients with painful osseous metastases.

Materials and methods

Thirty RF ablations were performed in 24 patients (mean age: 61?years) with bone metastases. Half of the patients had an additional PV. The primary end point was pain relief evaluated by a visual analogue scale (VAS) before treatment, and at 1 and 6?months?? FU. Functional outcome was assessed according to the evolution of their ability to walk at 6?months?? FU. Imaging FU was available in 20 out of 24 patients with a mean delay of 4.7?months.

Results

Reduction of pain was obtained at 6?months FU in 81% of cases (15 out of 18). Mean pretreatment VAS was 6.4 (±2.7). Mean VAS was 1.9 (±2.4) at 1?month FU, and 2.3 (±2.9) at 6?months?? FU. Pain was significantly reduced at 6?months FU (mean VAS reduction?=?4.1; P?<?0.00001). Functional improvement was obtained in 74% of the cases. Major complications rate was 12.5 % (3 out of 24) with 2 skin burns, and 1 case of myelopathy. Local tumour recurrence or progression was recorded in 5 cases.

Conclusion

Radiofrequency ablation is an effective technique in terms of pain relief and functional recovery for the treatment of bone metastases, which provides a relatively low rate of local recurrence.     

Upright Cone CT of the hindfoot: Comparison of the non-weight-bearing with the upright weight-bearing position

Objectives

To prospectively compare computed tomography (CT) of the hindfoot in the supine non-weight-bearing position (NWBCT) with upright weight-bearing position (WBCT).

Methods

Institutional review board approval and informed consent of all patients were obtained. NWBCT and WBCT scans of the ankle were obtained in 22 patients (mean age, 46.0?±?17.1 years; range 19–75 years) using a conventional 64-row CT for NWBCT and a novel cone-beam CT for WBCT. Two musculoskeletal radiologists independently performed the following measurements: the hindfoot alignment angle, fibulocalcaneal and tibiocalcaneal distances, lateral talocalcaneal joint space width, talocalcaneal overlap and naviculocalcaneal distance. Significant changes between NWBCT and WBCT were sought using Wilcoxon signed-rank test. P values <0.05 were considered statistically significant.

Results

Significant differences were found for all measurements except the hindfoot alignment angle and tibiocalcaneal distance. Significant measurement results were as follows (NWBCT/WBCT reader 1; NWBCT/WBCT reader 2, mean ± standard deviation): fibulocalcaneal distance 3.6 mm?±?5.2/0.3 mm?±?6.0 (P?=?0.006); 1.4 mm?±?6.3/-1.1 mm?±?6.3 (P?=?0.002), lateral talocalcaneal joint space width 2.9 mm?±?1.7/2.2 mm?±?1.1 (P?=?0.005); 3.4 mm?±?1.9/2.4 mm?±?1.3 (P?=?0.001), talocalcaneal overlap 4.1 mm?±?3.9/1.4 mm?±?3.9 (P?=?0.001); 4.5 mm?±?4.3/1.4 mm?±?3.7 (P?<?0.001) and naviculocalcaneal distance 13.5 mm?±?4.0/15.3 mm?±?4.7 (P?=?0.037); 14.0 mm?±?4.4/15.7 mm?±?6.2 (P?=?0.100). Interreader agreement was good to excellent (ICC 0.48–0.94).

Conclusion

Alignment of the hindfoot significantly changes in the upright weight-bearing CT position. Differences can be visualised and measured using WBCT.

Key Points

? Cone-beam computed tomography (CBCT) offers new opportunities for musculoskeletal problems ? Visualization and quantification of hindfoot alignment are possible in upright weight-bearing CBCT ? Hindfoot alignment changes significantly from non-weight-bearing to weight-bearing CT ? The weight-bearing position leads to a decrease in the fibulocalcaneal distance and talocalcaneal overlap ? The naviculocalcaneal distance is increased in the weight-bearing position     

Sclerosing polidocanol injections in mid-portion Achilles tendinosis: remaining good clinical results and decreased tendon thickness at 2-year follow-up

The short-term results after treatment with sclerosing polidocanol injections have been shown to be good in patients with chronic painful mid-portion Achilles tendinosis. This study aimed to evaluate the longer-term effects on tendon thickness, structure and vascularity, patient satisfaction with treatment, and pain during tendon loading activity. Ultrasonography (US) + colour Doppler (CD) was used for evaluation of the tendon, and the patients graded the amount of pain during tendon loading activity on a VAS. Forty-two patient’s tendons (23 men and 19 women, mean age 53 years) with a long duration (mean 32 months) of pain symptoms from mid-portion Achilles tendinosis (US + CD showed a localised thickening, structural changes and neovascularisation), were at three (mean) occasions (6–8 weeks in between) treated with US and CD guided injections of the sclerosing substance polidocanol, targeting the area with neovessels ventral to the tendon. After treatment, 37 patients were satisfied with the results of the treatment and back to previous (before injury) activity level. At the 2-year follow-up (mean 23 months), 38 patients were satisfied with the results of the treatment, and there was a significant reduction in VAS (from 75 to 7; P < 0.05). US showed a significant reduction in the mean mid-portion tendon thickness (from 10 to 8 mm, P < 0.05) and a “more normal” structure. CD showed no, or a few, remaining neovessels in the majority of the successfully treated tendons. In conclusion, treatment with sclerosing polidocanol injections in patients with chronic painful mid-portion Achilles tendinosis showed remaining good clinical results at a 2-year follow-up. Decreased tendon thickness and improved structure after treatment, might indicate a remodelling potential?     

The Erlangen Dose Optimization trial for low-dose radiotherapy of benign painful elbow syndrome

Background and purpose

To evaluate the long-term efficacy of pain reduction by two dose fractionation schedules used for low-dose radiotherapy of painful elbow syndrome.

Patients and methods

Between February 2006 and February 2010, 199 evaluable patients were recruited for this prospective trial. All patients received low-dose orthovoltage radiotherapy. One course consisted of 6 fractions in 3 weeks. In the case of insufficient pain remission after 6 weeks, a second course was administered. Patients were randomly assigned to one of two groups to receive single doses of either 0.5 or 1.0 Gy. Endpoint was pain reduction. Pain was measured before radiotherapy, as well as immediately after (early response), 6 weeks after (delayed response) and approximately 3 years after (long-term response) completion of radiotherapy using a questionnaire-based visual analogue scale (VAS) and a comprehensive pain score (CPS).

Results

Median follow-up was 35 months (range 9–57 months). The overall early, delayed and long-term response rates for all patients were 80, 90 and 94?%, respectively. The mean VAS scores before treatment and those for early, delayed and long-term response in the 0.5- and 1.0-Gy groups were 59.6?±?20.2 and 55.7?±?18.0 (p?=?0.46); 32.1?±?24.5 and 34.4?±?22.5 (p?=?0.26); 27.0?±?27.7 and 23.5?±?21.6 (p?=?0.82) and 10.7?±?15.0 and 21.5?±?26.9 (p?=?0.12), respectively. The mean CPS values before treatment and those for early, delayed and long-term response were 8.7?±?2.9 and 8.1?±?3.1 (p?=?0.21); 4.5?±?3.2 and 5.0?±?3.4 (p?=?0.51); 3.9?±?3.6 and 2.8?±?2.8 (p?=?0.19) and 1.5?±?2.3 and 2.4?±?3.5 (p?=?0.27), respectively. No significant differences in the quality of the long-term response were found between the 0.5- and 1.0-Gy arms (p?=?0.28).

Conclusion

Low-dose radiotherapy is an effective treatment for the management of benign painful elbow syndrome. For radiation protection reasons, the dose for a radiotherapy series should not exceed 3.0 Gy.     

The Erlangen Dose Optimization Trial for radiotherapy of benign painful shoulder syndrome

Background and purpose

To evaluate the long-term efficacy of pain reduction by two dose-fractionation schedules for radiotherapy of painful shoulder syndrome.

Patients and methods

Between February 2006 and February 2010, 312 evaluable patients were recruited for this prospective trial. All patients received low-dose orthovoltage radiotherapy. One course consisted of 6 fractions in 3 weeks. In the case of insufficient pain remission after 6 weeks, a second course was administered. Patients were randomly assigned to one of two groups to receive single doses of either 0.5 or 1.0 Gy. Endpoint was pain reduction. Pain was measured before radiotherapy, as well as immediately after (early response), 6 weeks after (delayed response) and approximately 3 years after (long-term response) completion of radiotherapy using a questionnaire-based visual analogue scale (VAS) and a comprehensive pain score (CPS).

Results

Median follow-up was 35 months (range 11–57). The overall early, delayed and long-term response rates for all patients were 83, 85 and 82?%, respectively. The mean VAS scores before treatment and those for early, delayed and long-term response in the 0.5- and 1.0-Gy groups were 56.8?±?23.7 and 53.2?±?21.8 (p?=?0.16); 38.2?±?36.1 and 34.0?±?24.5 (p?=?0.19); 33.0?±?27.2 and 23.7?±?22.7 (p?=?0.04) and 27.9?±?25.8 and 32.1?±?26.9 (p?=?0.25), respectively. The mean CPS values before treatment and those for early, delayed and long-term response were 9.7?±?3.0 and 9.5?±?2.7 (p?=?0.31); 6.1?±?3.6 and 5.4?±?3.6 (p?=?0.10); 5.3?±?3.7 and 4.1?±?3.7 (p?=?0.05) and 4.0?±?3.9 and 5.3?±?4.4 (p?=?0.05), respectively. No significant differences in the quality of the long-term response were found between the 0.5- and 1.0-Gy arms (p?=?0.28).

Conclusion

Radiotherapy is an effective treatment for the management of benign painful shoulder syndrome. For radiation protection reasons, the dose for a radiotherapy series should not exceed 3.0 Gy.     

Detection of invasive components in cases of breast ductal carcinoma in situ on biopsy by using apparent diffusion coefficient MR parameters

Objectives

To evaluate whether apparent diffusion coefficient (ADC) parameters could identify invasive components in cases with ductal carcinoma in situ (DCIS) diagnosed by biopsy.

Methods

This retrospective study was approved by the institutional review board and the requirement to obtain informed consent was waived. Sixty-nine consecutive women with 70 lesions diagnosed with DCIS by biopsy underwent breast magnetic resonance (MR) imaging. Multiple regions of interest were placed (as many as possible) within the lesion on ADC maps. The minimum ADC values and the ADC difference values obtained as the difference between minimum and maximum ADCs were evaluated.

Results

Surgical specimens revealed 51 lesions with pure DCIS and the remaining 19 lesions with DCIS with invasive components (DCIS-IC). The minimum ADC value for DCIS-IC (0.99?±?0.04?×?10^?3 mm²/s) was significantly lower than that of pure DCIS (1.15?±?0.03?×?10^?3 mm²/s) (P??=??0.0037). The ADC difference value for DCIS-IC (0.38?±?0.05?×?10^?3 mm²/s) was significantly higher than that of pure DCIS (0.17?±?0.03?×?10^?3 mm²/s). ROC curve analysis for differentiating DCIS-IC from pure DCIS revealed that the area under the curve was 0.71 for minimum ADC value and 0.77 for ADC difference value.

Conclusions

The minimum ADC values and ADC difference values could suggest the presence of invasive components.

Key Points

? Identification of invasive components in DCIS before treatment is clinically important. ? Diffusion-weighted MR imaging can help lesion assessment in breast cancer. ? The minimum ADC value may suggest the presence of an invasive component in DCIS. ? The ADC difference value also suggests the presence of an invasive component in DCIS. ? Preoperative evaluation of diffusion-weighted MR imaging may help surgical planning for DCIS.     

Dynamic contrast–enhanced ultrasonographic (DCE-US) assessment of the early response after combined gemcitabine and HIFU with low-power treatment for the mouse xenograft model of human pancreatic cancer

Purpose

To assess therapeutic efficacy of gemcitabine and HIFU for a mouse model of pancreatic cancer, and the role of DCE-US for predicting early treatment response compared with pathology.

Materials and methods

In 48 PANC-1- nude mice (G1, HIFU_higher power [n?=?14]; G2, gemcitabine [n?=?12]; G3, combined gemcitabine and HIFU_low power [n?=?12]; and G4, control [n?=?10]), pulsed HIFU or gemcitabine therapy was used. DCE-US was performed 1 day before and after first treatment. Seven DCE-US perfusion parameters were obtained. Therapeutic efficacy was estimated using necrotic fraction and apoptosis. Correlation between tumour size and US perfusion parameters was analysed.

Results

Pathology results showed that combined gemcitabine and HIFU using low-power treatment had a more effective response than other treatments, including in the control group, i.e. necrotic fraction: 40.5?±?4.9 vs. 16.9?±?8.0, p?=?0.000 and apoptosis: 44.3?±?29.4 vs. 7.9?±?4.9, p?=?0.002. In this group, US perfusion parameters, including peak intensity (22.6?±?22.6 vs. 9.6?±?6.3, p?=?0.002), AUC (961.8?±?96.9 vs. 884.4?±?91.4, p?=?0.000), and AUC_out (799.9?±?75.6 vs. 747.1?±?77.9, p?=?0.000), had significantly decreased 1 day following first treatment (p?out showed a tendency to decrease in treated groups. Alternatively, peak intensity, AUC, and AUC_out showed a tendency to increase in control group.

Conclusion

Gemcitabine and HIFU were more effective and safer than other treatments. US perfusion parameters were useful for predicting early therapeutic response 1 day following treatment.

Key points

? Recently, treatment of pancreatic cancer has changed based on a multidisciplinary approach. ? Combined gemcitabine_HIFU demonstrated more effective therapeutic response than other treatments. ? DCE-US is useful for predicting early therapeutic response 1 day after treatment. ? In the combined group, PI, AUC, and AUC ^out decreased 1 day after treatment.     

Hypocalcaemia after treatment with [177Lu-DOTA0,Tyr3]octreotate

Purpose

The aim of this study was to explore the possible mechanisms involved in an observed decline in serum calcium levels in patients with a neuroendocrine tumour (NET) treated with [¹⁷⁷Lu-DOTA⁰,Tyr³]octreotate (¹⁷⁷Lu-octreotate).

Methods

In 47 patients with NET who were normocalcaemic at baseline, serum calcium, albumin, creatinine, alkaline phosphatase, gamma glutamyl transpeptidase, magnesium, phosphate and 25-hydroxyvitamin D were prospectively analysed at baseline and up to 6 months after treatment. Parathyroid hormone (PTH), 1,25-dihydroxyvitamin D₃, type 1 aminoterminal propeptide of procollagen, bone-specific alkaline phosphatase, carboxyterminal crosslinking telopeptide of bone collagen, collagen type I crosslinked N-telopeptide, and creatinine and calcium in 24-h urine samples, were evaluated at baseline and at 3 and 6 months. Another 153 patients with NET were included in a retrospective study to estimate the occurrence of hypocalcaemia in a larger patient group.

Results

In the prospectively included patients, the mean serum calcium level decreased significantly after treatment (2.31?±?0.01 to 2.26?±?0.02 mmol/l, p?=?0.02). Eight patients (17 %) showed a marked decrease in serum calcium levels with a nadir of ≤2.10 mmol/l. In five patients (11 %), calcium substitution therapy was prescribed. PTH increased significantly (5.9?±?0.6 to 6.7?±?0.8 pmol/l, p?=?0.02), presumably in response to the decreasing serum calcium levels. 25-Hydroxyvitamin D remained stable after treatment. Creatinine levels increased significantly (73?±?3 to 77?±?3 μmol/l, p?=?0.01), but not enough to explain the hypocalcaemia. Phosphate levels remained unaffected. In the retrospectively analysed patients, the mean serum calcium level decreased significantly from 2.33?±?0.01 at baseline to a nadir of 2.24?±?0.01 mmol/l at 18 months after treatment (p?<?0.001). Of the 153 patients, 33 (22 %) showed a serum calcium nadir of ≤2.10 mmol/l, and 11 (7 %) received calcium substitution therapy.

Conclusion

The mean serum calcium level decreased significantly after treatment with ¹⁷⁷Lu-octreotate, resulting in mild hypocalcaemia in about 20 % of patients. We excluded several potential causes of this hypocalcaemia, so the cause remains unknown. Serum calcium levels should be monitored after peptide receptor radionuclide therapy, and calcium substitution therapy should be initiated if appropriate.     

Chronic mitral regurgitation detected on cardiac MDCT: differentiation between functional and valvular aetiologies

Objective

To determine whether cardiac computed tomography (MDCT) can differentiate between functional and valvular aetiologies of chronic mitral regurgitation (MR) compared with echocardiography (TTE).

Methods

Twenty-seven patients with functional or valvular MR diagnosed by TTE and 19 controls prospectively underwent cardiac MDCT. The morphological appearance of the mitral valve (MV) leaflets, MV geometry, MV leaflet angle, left ventricular (LV) sphericity and global/regional wall motion were analysed. The coronary arteries were evaluated for obstructive atherosclerosis.

Results

All control and MR cases were correctly identified by MDCT. Significant differences were detected between valvular and control groups for anterior leaflet length (30?±?7 mm vs. 22?±?4 mm, P?<?0.02) and thickness (3.0?±?1 mm vs. 2.2?±?1 mm, P?<?0.01). High-grade coronary stenosis was detected in all patients with functional MR compared with no controls (P?<?0.001). Significant differences in those with/without MV prolapse were detected in MV tent area (?1.0?±?0.6 mm vs. 1.3?±?0.9 mm, P?<?0.0001) and MV tent height (?0.7?±?0.3 mm vs. 0.8?±?0.8 mm, P?<?0.0001). Posterior leaflet angle was significantly greater for functional MR (37.9?±?19.1° vs. 22.9?±?14°, P?<?0.018) and less for valvular MR (0.6?±?35.5° vs. 22.9?±?14°, P?<?0.017). Sensitivity, specificity, and positive and negative predictive values of MDCT were 100%, 95%, 96% and 100%.

Conclusion

Cardiac MDCT allows the differentiation between functional and valvular causes of MR.