Solitary late metastasis of primary renal cell carcinoid tumor to the extraocular muscles imaged with indium-111 octreotide.

A 75-year-old male presented with right eye pain and proptosis. His history was significant for renal cell carcinoma treated with left nephrectomy 2 years previously. Computed tomography (CT) imaging demonstrated a 1.6-cm enhancing lesion in the right retrobulbar space. Surgical biopsy revealed a low-grade metastatic carcinoid tumor. At retrospective review, the primary renal lesion from 2 years prior was rediagnosed as consistent with a renal carcinoid tumor. Indium-111 octreotide single photon emission CT/CT imaging demonstrated a solitary metastasis within the right extraocular muscles. The patient subsequently developed additional metastases within the remaining right kidney and lung.

Carotid atherosclerotic plaques standardised uptake values: software challenges and reproducibility.

BACKGROUND: Positron emission tomography-computed tomography (PET-CT) carotid standardised uptake values (SUV) of 18F-fluorodeoxyglucose (18FDG) have been proposed as an inflammatory biomarker for determining cerebrovascular diseases such as stroke. Consideration of varying methodological approaches and software packages is critical to the calculation of accurate SUVs in cross-sectional and longitudinal patient studies. The aim of this study was to investigate whether or not carotid atherosclerotic plaque SUVs are consistent and reproducible between software packages. 18FDG-PET SUVs of carotids were taken in 101 patients using two different software packages. Quality assurance checks were performed to standardise techniques before commencing the analysis where data from five to seven anatomical sites were measured. A total of ten regions of interest were drawn on each site analysed. Statistical analyses were then performed to compare SUV measurements from the two software packages and to explore reproducibility of measurements. Lastly, the time taken to complete each analysis was measured and compared. RESULTS: Statistically significant differences in SUV measurements, between the two software packages, ranging from 9 to 21.8% were found depending on ROI location. In 79% (n = 23) of the ROI locations, the differences between the SUV measurements from each software package were found to be statistically significant. The time taken to perform the analyses and export data from the software packages also varied considerably. CONCLUSIONS: This study highlights the importance of standardising all aspects of methodological approaches to ensure accuracy and reproducibility. Physicians must be aware that when a PET-CT data set is analysed, subsequent follow-ups must be verified, if possible, with the same software package or cross-calibration between packages should be performed.

Impact of sensory design interventions on image quality, patient anxiety and overall patient experience at MRI.

OBJECTIVE: This study aimed to assess the effect of sensory stimulation on patient MRI experience and to assess whether sensory stimulation has a significant effect on MR image quality. METHODS: A case-control study was conducted over 4 months, involving patients undergoing MRI brain, cervical spine, breast and prostate. The study involved 106 patients, 64 cases and 42 controls. Cases underwent sensory stimulation during the scan in the form of a scented cotton pad placed in the scanner near their head and/or calming bird noises were played over headphones. Post-scan, participants completed a questionnaire regarding their experience of MRI. Scanning radiographers completed a questionnaire regarding patient tolerance of the scan. All studies were evaluated by two radiologists for the presence of movement artefact. RESULTS: 39% of cases and 38% of controls reported anxiety in the days preceding MRI. 6.2% of cases required coaching during image acquisition, while 9.7% of controls required coaching. 4.7% of cases and 4.8% controls required sequence repetition owing to movement artefact. Mean patient experience score (as graded by the patient) for controls was 1.74 ± 0.63 standard deviation (SD) and for cases, it was 1.67 ± 0.60 SD. (Lower assigned scores equated to a better experience). Mean patient experience score based on comments on a 5-point scale as graded by two observers was 2.81 ± 0.70 SD for controls, 2.42 + 0.94 SD for sound intervention and 2.46 ± 1.01 SD for scent intervention. Mean motion artefact score graded by the two radiologists was 1.13 ± 0.53 SD for controls and 1.08 ± 0.36 SD for cases. (A lower score equated to less movement artefact). We demonstrated a trend towards a relaxing experience in those patients undergoing MRI for the first time who underwent sensory intervention. Participant positive ratings of the smell pleasantness were associated with a reduced likelihood of experiencing anxiety (p = 0.13). Results were not statistically significant. CONCLUSION: This study demonstrated a subjectively improved experience of MRI for some patients with the intervention of sound and smell. The study failed to show a significant decrease in patient movement during MRI investigations. This may relate to the small study size and a low level of patient movement in the case group. Advances in knowledge: Sound and olfactory sensory environment interventions at MRI can improve the patient experience. These low-cost interventions are well tolerated, may improve acceptance of MRI in patients with anxiety and offer a competitive advantage to imaging centres.

Semiautomatic region-of-interest validation at the femur in (18)F-fluoride PET/CT.

UNLABELLED: The assessment of regional skeletal metabolism using (18)F-fluoride PET ((18)F-PET) requires segmentation of the tissue region of interest (ROI). The aim of this study was to validate a novel approach to define multiple ROIs at the proximal femur similar to those used in dual x-ray absorptiometry. Regions were first drawn on low-dose CT images acquired as a routine part of the PET/CT study and transferred to the (18)F-PET images for the quantitative analysis of bone turnover. METHODS: Four healthy postmenopausal women with a mean age of 65.1 y (range, 61.8-70.0 y), and with no history of metabolic bone disorder and not currently being administered treatment affecting skeletal metabolism, underwent dynamic (18)F-PET/CT at the hip with an injected activity of 180 MBq. The ROIs at the proximal femur included femoral shaft, femoral neck, and total hip and were segmented using both a semiautomatic method and manually by 8 experts at manual ROI delineation. The mean of the 8 manually drawn ROIs was considered the gold standard against which the performances of the semiautomatic and manual methods were compared in terms of percentage overlap and percentage difference. The time to draw the ROIs was also compared. RESULTS: The percentage overlaps between the gold standard and the semiautomatic ROIs for total hip, femoral neck, and femoral shaft were 86.1%, 37.8%, and 96.1%, respectively, and the percentage differences were 14.5%, 89.7%, and 4.7%, respectively. In the same order, the percentage overlap between the gold standard and the manual ROIs were 85.2%, 39.1%, and 95.2%, respectively, and the percentage differences were 19.9%, 91.6%, and 12.2%, respectively. The semiautomatic method was approximately 9.5, 2.5, and 67 times faster than the manual method for segmenting total-hip, femoral-neck, and femoral-shaft ROIs, respectively. CONCLUSION: We have developed and validated a semiautomatic procedure whereby ROIs at the hip are defined using the CT component of an (18)F-PET/CT scan. The percentage overlap and percentage difference results between the semiautomatic method and the manual method for ROI delineation were similar. Two advantages of the semiautomatic method are that it is significantly quicker and eliminates some of the variability associated with operator or reader input. The tube current used for the CT scan was associated with an effective dose 8 times lower than that associated with a typical diagnostic CT scan. These results suggest that it is possible to segment bone ROIs from low-dose CT for later transfer to PET in a single PET/CT procedure without the need for an additional high-resolution CT scan.

Crossover comparison of IPX066 and a standard levodopa formulation in advanced Parkinson's disease.

The objective of the study was to compare the pharmacokinetics, motor effects, and safety of IPX066, a novel extended-release formulation of carbidopa-levodopa, with an immediate-release carbidopa-levodopa formulation in advanced Parkinson's disease. We performed an open-label crossover study in 27 subjects with advanced Parkinson's disease experiencing motor fluctuations on levodopa therapy. Subjects were randomized 1:1 to 8 days' treatment with either immediate-release carbidopa-levodopa followed by IPX066 or IPX066 followed by immediate-release carbidopa-levodopa. Pharmacokinetic and motor assessments were undertaken on day 1 for 8 hours (following a single dose) and on day 8 for 12 hours (during multiple-dose administration). Following a single dose of IPX066 or immediate-release carbidopa-levodopa, plasma levodopa concentrations increased at a similarly rapid rate and were sustained above 50% of peak concentration for 4 hours with IPX066 versus 1.4 hours with immediate-release carbidopa-levodopa (P < .0001). Multiple-dose data showed IPX066 substantially reduced variability in plasma levodopa concentrations despite a lower dosing frequency (mean, 3.5 vs 5.4 administrations per day). In addition, total levodopa exposure during IPX066 treatment was approximately 87% higher, whereas the increase in levodopa C(max) was approximately 30% compared with immediate-release carbidopa-levodopa. Both products were well tolerated. IPX066 provided more sustained plasma levodopa concentrations than immediate-release carbidopa-levodopa. Larger, longer-term, well-controlled studies should be conducted to provide rigorous assessment of the clinical effects of IPX066.

Whole-body imaging modalities in oncology.

This article outlines the expanding approaches to whole-body imaging in oncology focusing on whole-body MRI and comparing it to emerging applications of whole-body CT, scintigraphy, and above all PET CT imaging. Whole-body MRI is widely available, non-ionizing and rapidly acquired, and inexpensive relative to PET CT. While it has many advantages, WBMRI is non-specific and, when compared to PET CT, is less sensitive. This article expands each of these issues comparing individual modalities as they refer to specific cancers.

Whole-Body MRI versus PET in assessment of multiple myeloma disease activity.

OBJECTIVE: The purpose of this study was to compare FDG PET; whole-body MRI; and the reference standard, bone marrow aspiration and biopsy, to determine the best imaging technique for assessment of disease activity in multiple myeloma. SUBJECTS AND METHODS: Twenty-four patients (13 women, 11 men; mean age, 67.1 years; range, 44-83 years) with bone marrow biopsy-proven multiple myeloma were included in the study. All patients underwent PET/CT and whole-body MRI within 10 days of each other. Eight patients underwent more than one follow-up PET/CT and whole-body MRI examination, for a total of 34 pairs of images. Activity was defined as lesions with a maximum standardized uptake value greater than 2.5 at PET and as evidence of marrow packing at whole-body MRI. PET and whole-body MRI results were correlated with findings at bone marrow aspiration biopsy. RESULTS: PET had a sensitivity of 59%, specificity of 75%, positive predictive value of 81%, and negative predictive value of 50% (p = 0.08). Whole-body MRI had a sensitivity of 68%, specificity of 83%, positive predictive value of 88%, and negative predictive value of 59% (p = 0.01). In 62% of cases, PET and whole-body MRI findings were concordant. When PET and whole-body MRI findings were concordant and positive, no false-positive results were found, yielding a specificity and a positive predictive value of 100% (p = 0.04). CONCLUSION: Whole-body MRI performed better than PET in the assessment of disease activity, having a higher sensitivity and specificity. The positive predictive value of whole-body MRI in the assessment of active disease was high at 88%. When used in combination and with concordant findings, PET and whole-body MRI were found to have a specificity and positive predictive value of 100%, which may be of value to clinicians assessing the effectiveness of aggressive and expensive treatment regimens.

Coronal oblique turbo STIR imaging of the sacrum and sacroiliac joints at routine MR imaging of the lumbar spine.

The objective of the study was to evaluate the clinical impact of coronal oblique imaging of the lumbrosacral junction and the sacrum at initial presentation for MR imaging of the lumbar spine in patients presenting with low back pain or sciatic pain. Two hundred and sixty consecutive patients attending for MRI of the lumbar spine underwent simultaneous coronal oblique turbo short tau inversion recovery (STIR; TR 2500, TE 40, TI 150, echo train length 7, number of scan acquisitions 2) imaging of the sacrum and the sacroiliac joints with a field of view of 30-cm and 3-mm slices (acquisition time 3 min and 20 s). Images were reviewed by two experienced radiologists to determine the cause of back pain, with and without images of the sacrum and sacroiliac joints. The added value of the additional sequence was assessed. Correlation was made with surgery, response to nerve root injection or clinical follow-up at 3 months. Subgroup analysis was performed to determine if patient stratification according to sex or symptoms would be useful. In total, in 19 of 260 patients (7.3%), abnormalities were identified at coronal STIR imaging. In 7 of 260 patients (2.7%), pathology was identified in the sacrum thought to account for back pain, altering the diagnosis made on the standard sequences. These diagnoses were sacroiliitis (n=2), sacral stress fracture (n=1), degenerative sacroiliac joints (n=1), degenerative accessory articulation between the lumbar spine and the sacrum (n=1), Tarlov cyst of nerve root (n=1) and retroverted uterus causing sciatic pain (n=1). Patient stratification according to sex or the presence or absence of sciatic symptoms was not useful in predicting the added benefit of the additional sequence. Routine coronal STIR imaging of the sacrum as part of lumbar spine MRI improves assessment of patients presenting with low back pain or sciatica in only a small number of patients.

MDCT of abdominal wall hernias: is there a role for valsalva's maneuver?

OBJECTIVE: Our objective was to evaluate the role of Valsalva's maneuver during MDCT for the diagnosis and characterization of abdominal wall hernias. SUBJECTS AND METHODS: From September 2002 to May 2003, 100 consecutive patients (37 men and 63 women; mean age, 53 years) with suspected anterior abdominal wall hernias underwent 4-, 8-, or 16-MDCT with and without Valsalva's maneuver. Patients received both oral and IV contrast material. On a workstation, three independent reviewers evaluated each scan obtained during rest and during Valsalva's maneuver for the following parameters: anteroposterior (AP) diameter of the abdomen; presence, location, and contents of the hernia; and transverse diameter of the fascial defect. The scans were compared to assess for changes in hernia size and contents and to determine whether the hernia would have been overlooked without Valsalva's maneuver. Fisher's exact test, the McNemar test, and Cohen's kappa coefficient were used to assess for significant differences. RESULTS: The three reviewers identified a mean of 72 abdominal wall hernias (72%). The reviewers agreed (kappa = 0.723) with respect to the presence of a hernia. AP diameters increased an average of 1.33 cm during Valsalva's maneuver (p < 0.001). The transverse diameter of the fascial defect increased an average of 0.66 cm and the AP diameter of the hernia sac increased an average of 0.79 cm during Valsalva's maneuver (p < 0.001). Fifty percent of the hernias became more apparent with Valsalva's maneuver. Ten percent of the hernias could be detected only on the scan obtained during Valsalva's maneuver. Conversely, in no patients was the hernia detected only on the rest scan. CONCLUSION: As opposed to scans obtained at rest, scans obtained during Valsalva's maneuver aid in the detection and characterization of suspected abdominal wall hernias. A single scan obtained during Valsalva's maneuver is sufficient to detect 100% of anterior abdominal wall hernias identified on CT.

Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation.

PURPOSE: To determine whether the secondary cleft sign demonstrated in the symphysis pubis at magnetic resonance (MR) imaging is a marker of injury in athletes presenting with groin pain. MATERIALS AND METHODS: Ethics review board approval was not required for studies involving retrospective image or case record review; informed consent for review was not required. Eighteen male athletes (mean age, 24 years; age range, 19-32 years) were included for study. All patients underwent radiography and MR imaging (coronal fast spin-echo T1-weighted, transverse fast spin-echo T2-weighted, and coronal turbo short inversion time inversion-recovery [STIR] imaging) of the pelvis. Subsequent image-guided nonionic contrast material injection was followed by a 0.5% bupivacaine hydrochloride (1 mL) and methyprednisolone acetate (20 mg) injection into the central cleft of the symphysis pubis. Comparison was made between imaging findings at symphyseal cleft injection and appearances at preprocedure MR imaging, with specific reference to the presence of a secondary cleft. The sensitivity and specificity of MR imaging in demonstrating the secondary cleft sign were compared with those of the reference standard, imaging at symphyseal cleft injection. MR images from a reference group of 70 asymptomatic athletes who underwent STIR imaging of the pelvis were analyzed for evidence of a secondary cleft. RESULTS: Osteitis pubis was diagnosed in six patients on the basis of radiography and/or MR imaging. A secondary cleft was identified in 12 of 18 patients at MR imaging, was best visualized at coronal STIR imaging, and was confirmed in each patient during contrast material injection into the central physiologic symphyseal cleft. In no patient was a secondary cleft identified at symphyseal cleft injection and not identified at MR imaging (sensitivity and specificity, 100%). In each patient, the side of the secondary cleft corresponded to the side of symptoms that responded to local anesthetic and steroid injection. Four of the six patients with osteitis pubis had evidence of a secondary cleft. In one patient, a secondary cleft was not identified at MR imaging or symphyseal cleft injection, but adductor avulsion was identified at MR imaging. No evidence of a secondary cleft sign at MR imaging was identified in the reference group. CONCLUSION: The secondary cleft sign demonstrated at MR imaging is a marker of groin injury in athletes presenting with groin pain.

Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes.

OBJECTIVE: The purpose of this study was to describe the application, technique, and results of symphyseal cleft injection in athletes with osteitis pubis. CONCLUSION: Symphyseal cleft injection is a useful technique for the diagnosis and treatment of osteitis pubis in athletes. The procedure is well tolerated and may facilitate early resumption of competitive duties.

Whole-body MR imaging in the diagnosis of polymyositis.

OBJECTIVE: Our purpose was to evaluate the use of whole-body MR imaging in the assessment of the extent and distribution of muscle inflammation in patients with polymyositis. CONCLUSION: Whole-body turbo short tau inversion recovery imaging is a convenient complete method of evaluating patients with muscle inflammation caused by polymyositis. This imaging technique allows us to evaluate the total inflammatory burden by revealing multiple muscle groups not seen with standard protocols.

Non-invasive investigation and management of aortic saddle embolus in a 7-month-old infant.

There are few reports in the literature on the ultrasound appearance of aortic saddle embolus, and none relating to small children. This unusual condition is usually diagnosed angiographically. The purpose of this report is to show how effectively high-frequency ultrasound can identify a saddle embolus with its associated collateral circulation in a young child, and to demonstrate its usefulness in monitoring the efficacy of treatment. In this case the embolus occurred as a complication of parvovirus B19 myocarditis and was diagnosed and followed up entirely by ultrasound examination, with no invasive procedure performed. The early development of an extensive collateral circulation prevented distal tissue necrosis and allowed a conservative approach to management.