MRI signal and morphological alterations of the suprapatellar fat pad in asymptomatic subjects: are these normal variants?

OBJECTIVE: To study the prevalence of suprapatellar fat pad (SPFP) MR alterations in asymptomatic subjects, in relation to a wide range of clinical/imaging parameters, including muscle performance tests and physical activity data. MATERIALS AND METHODS: We prospectively included 110 asymptomatic subjects as part of a cohort study. Inclusion criteria were no knee pain in the last year. Exclusion criteria were any medical/surgical history of a knee disorder. Subjects underwent knee and low-dose posture radiographs [EOS®], 3 T MRI, clinical examination including muscle performance tests, and physical activity monitoring. The presence/absence of SPFP alterations (hyperintensity and mass effect) were assessed through consensus reading on fluid-sensitive sequences. Differences between groups of knees with SPFP alterations and controls were tested for a total of 55 categorical/continuous clinical/imaging parameters, including SPFP relative-T2-signal, trochlear/patellar/lower-limb morphologic measurements. Wilcoxon-rank-sum and chi-square tests were used to compare groups of patients. The histological correlation was obtained in a cadaveric specimen. RESULTS: SPFP alterations were common in asymptomatic subjects: hyperintensity 57% (63/110) and mass effect 37% (41/110), with 27% (30/110) showing both. Among the 55 imaging, clinical, or activity parameters tested, only increased patellar tilt angle (p = 0.02) and TT-TG distance (p = 0.03) were statistically different between groups of SPFP alterations and controls. The histological correlation showed more abundant connective tissue in SPFP compared to the prefemoral fat pad. CONCLUSIONS: SPFP hyperintensity and mass effect are common MRI findings in asymptomatic knees, and they are not related to most imaging, clinical, and activity parameters. Care should be taken not to overcall them pathological findings as they most likely represent normal variants.

MRI of non-specific low back pain and/or lumbar radiculopathy: do we need T1 when using a sagittal T2-weighted Dixon sequence?

OBJECTIVE: To show that for the MRI workup of non-specific low back pain and/or lumbar radiculopathy, the acquisition of T1-weighted sequences in the sagittal plane could be waived when using an FSE T2-weighted Dixon sequence. MATERIALS AND METHODS: Three musculoskeletal radiologists retrospectively reviewed fifty lumbar spine MRI examinations performed for non-specific low back pain and/or lumbar radiculopathy. Two protocols were separately analyzed in the sagittal plane: a standard protocol (T1-weighted, in-phase, and water-only images of an FSE T2-weighted Dixon sequence) and a simplified protocol (fat-only, in-phase, and water-only images of an FSE T2-weighted Dixon sequence). Eight items usually assessed on T1-weighted sequences were analyzed for each of the vertebrae (n = 250), vertebral endplates (n = 500), vertebral corners (n = 1000), foramina (n = 500), lamina (n = 500), and facet joints (n = 500). Interchangeability of these protocols was tested using the individual equivalence index. A decrease in interobserver agreement of ≥ 5% when one reader used the simplified protocol compared with when both readers used the standard protocol was considered clinically significant. Interreader and intrareader agreement were assessed using kappa statistics. Rates of findings with each protocol were compared using odd ratios. RESULTS: The standard and simplified protocols were interchangeable (range of upper bound of the 95%CI of individual equivalence index = 0.25 to 1.38%). Intraprotocol and interprotocol interreader kappa values were similar (0.253-0.671 vs. 0.236-0.723, respectively). Rates of findings were not statistically significantly different (p ≥ 0.074), or were higher with the simplified protocol (p ≤ 0.036). CONCLUSION: In our target population, a single sagittal T2-weighted Dixon sequence may replace the recommended combination of T1-, T2-, and fat-suppressed T2-weighted sequences. KEY POINTS: • In patients with non-specific low back pain or lumbar radiculopathy, spine MRI in the sagittal plane could be limited to a single FSE T2-weighted Dixon sequence, hereby reducing the acquisition time. • A simplified protocol of spine MRI in the sagittal plane combining FSE T2-weighted Dixon sequence provides the same information as a standard protocol including T1-, T2-, and fat-suppressed T2-weighted sequences for the workup of degenerative lumbar spine lesions. • For some findings shown on the simplified protocol, such as focal bone marrow replacement lesions or signs of infection, additional sequences including pre- and post-contrast T1-weighted sequences may be required, as is currently the case when using the standard protocol.

Bone Marrow Metastases: T2-weighted Dixon Spin-Echo Fat Images Can Replace T1-weighted Spin-Echo Images.

Purpose To test the potential of Dixon T2-weighted fat-only sequences to replace T1-weighted sequences for the detection of bone metastases, with the hypothesis that diagnostic performance with an alternative magnetic resonance (MR) imaging protocol (sagittal spin-echo Dixon T2-weighted fat-only and water-only imaging) would not be inferior to that with the standard protocol (sagittal spin-echo T1-weighted and spin-echo Dixon T2-weighted water-only imaging). Materials and Methods A total of 121 consecutive whole-spine MR imaging examinations (63 men; mean age ± standard deviation, 61.4 years ± 11.8) performed for suspected vertebral bone metastases were included in this retrospective, institutional review board-approved study. Quantitative image analysis was performed for 30 randomly selected spine levels. Qualitative analysis was performed separately by two musculoskeletal radiologists, who registered the number of metastases for each spine level. Areas under the curve with the protocols were compared on the basis of nonparametric receiver operating characteristic curve estimations by using a noninferiority test on paired data, with a best valuable comparator as a reference. Interobserver and interprotocol agreement was assessed by using κ statistics. Results Contrast-to-noise ratio was significantly higher on the alternative protocol images than on the standard protocol images (181.1 [95% confidence interval: 140.4, 221.7] vs 84.7 [95% confidence interval: 66.3, 103.1] respectively; P < .001). Diagnostic performance was not significantly inferior with the alternative protocol than with the standard protocol for both readers in a per-patient analysis (sensitivity, 97.9%-98.9% vs 93.6%-97.9%; specificity, 85.2%-92.6% vs 92.6%-96.3%; area under the curve, 0.92-0.96 vs 0.95, respectively; all P ≤ .02) and a per-spine level analysis (all P < .01). Interobserver and interprotocol agreement was good to very good (κ = 0.70-0.81). Conclusion Dixon T2-weighted fat-only and water-only imaging provide, in one sequence, diagnostic performance similar to that of the standard combination of morphologic sequences for the detection of probable spinal bone metastases, thereby providing an opportunity to reduce imaging time by eliminating the need to perform T1 sequences. © RSNA, 2017 An earlier incorrect version of this article appeared online. This article was corrected on November 6, 2017.

Thoracic spinous process nonunion as an unusual cause of back pain: a case report and review of the literature.

BACKGROUND: Purely isolated spinous processes fractures are rare and are usually treated conservatively, although a few authors have reported cases of nonunion that ultimately required surgical resection. CASE PRESENTATION: We present a case of an isolated T6 spinous process pseudoarthrosis that was treated by surgical resection of the tip of the spinous process. A 34-year-old Caucasian male patient was complaining of mid-thoracic back pain without neurologic impairment more than 2 years after an isolated spinous process fracture. Magnetic Resonance Imaging (MRI) and Single Photon Emission Computed Tomography (SPECT) revealed a nonunion. We performed a resection without further complication. CONCLUSION: Although spinous process nonunions may in some cases be well tolerated, surgical resection appears to be a reliable option in case of persistent symptoms. This illustrated case shows the description of an isolated thoracic spinous process nonunion and its surgical treatment.

Diffusion-weighted MRI in pretreatment prediction of response to neoadjuvant chemotherapy in patients with breast cancer.

PURPOSE: To evaluate the accuracy of the apparent diffusion coefficient (ADC) provided by diffusion-weighted imaging (DWI) in predicting the response to neoadjuvant chemotherapy (NACT) at baseline in patients according to their breast tumour phenotypes. MATERIALS & METHODS: This retrospective study was approved by our institutional review board. One hundred eighteen consecutive women with locally advanced breast cancer who had undergone NACT followed by breast surgery were included. DWI was performed at 1.5 T less than 2 weeks before NACT. We studied the correlation between pretreatment ADC and response in pathology after surgery according to immunohistochemical features and intrinsic subtypes (luminal A, luminal B, HER2-enriched, and triple-negative tumours). RESULTS: After surgery, the pathologist recognized 24 complete responders (CRps) and 94 non-complete responders (NCRps). No difference was identified between the pretreatment ADCs of the CRp and NCRp patients. There were differences in pretreatment ADCs among the luminal A (1.001 ± 0.143 × 10(-3) mm(2)/s), luminal B (0.983 ± 0.150 × 10(-3) mm(2)/s), HER2-enriched (1.132 ± 0.216 × 10(-3) mm(2)/s), and triple-negative (1.168 ± 0.245 × 10(-3) mm(2)/s; P = 0.0003) tumour subtypes. In triple-negative tumours, the pretreatment ADC was higher in NCRp (1.060 ± 0.143 × 10(-3) mm(2)/s) than in CRp patients (1.227 ± 0.271 × 10(-3) mm(2)/s; P = 0.047). CONCLUSION: Pretreatment ADC can predict the response of breast cancer to NACT if tumour subtypes are considered. Key Points • Apparent diffusion coefficient helps clinicians to assess patients with breast cancer. • Pretreatment ADC is related to tumour grade and hormone receptor status. • Pretreatment ADC is lower in luminal A and B than in triple-negative tumours. • Pretreatment ADC is higher in complete than in non-complete responders to neoadjuvant chemotherapy.

Considerations on the Relevance of Cerebral Fusiform Aneurysms Observed During HIV Infection.

Human immunodeficiency virus (HIV)-associated ectatic cerebral vasculitis (HIV-AECV) is a rare form of vasculitis with diffuse fusiform aneurysms. Its pathophysiology remains poorly understood. Although extensively described in children, it is still incompletely studied in adults. Our objective was to present five adult cases with emphasis on imaging findings and long-term evolution. From 2006 to 2014, we included 5 HIV-infected patients presenting with fusiform cerebral aneurysms. Vessels abnormalities were assessed with brain computed tomography (CT) angiography, magnetic resonance angiography (MRA) and/or digital subtraction angiography (DSA). All patients had MR assessment of the brain. Clinical and biological data were analyzed. Fusiform aneurysms of carotid terminations extending to middle and anterior cerebral arteries were bilateral in three patients and unilateral in one. More distal fusiform aneurysms were observed in four patients and saccular aneurysms in two patients, two patients suffered from ischemic lesions while none experienced hemorrhage. Unlike recent reviews, our study underlines the low hemorrhagic potential of HIV-AECV and long-term follow-up suggests a monophasic evolution under antiretroviral medication.

Control of Fusarium verticillioides (Sacc.) Nirenberg and Fumonisins by Using a Combination of Crop Protection Products and Fertilization.

Fusarium verticillioides is the most common fungal pathogen associated with maize ear rot in Tanzania. In a two-year trial, we investigated the efficacy of crop protection (insecticide and/or fungicide) and fertilizer (nitrogen and/or phosphorus) treatments in reducing the occurrence of F. verticillioides and its mycotoxins in maize grown in Tanzania. Seasonal differences were seen to have a substantial influence on the incidence and severity of insect infestation, Fusarium ear and kernel rot, biomass of F. verticillioides and contamination with fumonisins. With regard to the application of fertilizers, it was concluded that the impact on maize stalk borer injury, Fusarium symptoms and fumonisin levels was not significant, whereas crop protection significantly reduced maize damage. The application of an insecticide was most effective in reducing insect injury and as a result of the reduced insect injury the insecticide treatment also resulted in a significant decrease in Fusarium symptoms. In 2014, fumonisin levels were also significantly lower in maize treated with an insecticide. Additionally, significant positive correlations between insect damage and Fusarium symptoms were observed. In conclusion, this study clearly shows that application of an insecticide alone or in combination with a fungicide at anthesis significantly reduces insect damage and consequently reduces F. verticillioides infection and associated fumonisin contamination.

Amaurose por neuropatia óptica traumática direta secundária à corpo estranho transorbitário: relato de um caso atípico / Amaurosis by Traumatic Optic Neuropathy direct secondary to the "transorbitario" foreign body: Report of an atypical case

Resumo Neste trabalho descreve-se o caso clínico de um paciente do sexo masculino que evoluiu para cegueira tardia por neuropatia óptica traumática após queda de bicicleta. Enfatiza-se a importância do exame oftalmológico/reflexos pupilares e da tomografia computadorizada no diagnóstico de corpo estranho orbitário, sua remoção cirúrgica, abordagem interdisciplinar e evolução.

Abstract The purpose of this research is to describe a clinical study of a male patient who experienced late-blindness due to traumatic optic neuropathy after getting into a bicycle accident. It is stressed the importance of performing pupillary/reflexes examination and computed tomography scan in order to diagnose "transorbitário" foreign body. It is also cover its surgical removal as well as an interdisciplinary approach and clinical evolution.

Úlcera de Marjolin: revisão de literatura e relato de caso / Marjolin's Ulcer: literature review and report of a case / Úlcera de Marjolin: revisión de la Literatura y informe de caso clínico

Objetivo: Revisão narrativa de literatura e descrição de um caso de úlcera de Marjolin conduzido nas dependências do Hospital Escola Luiz Gioseffi Jannuzzi, enfatizando a conduta e evolução a partir da literatura e a adotada no caso abordado. Relato de Caso: Homem de 52 anos, com história de queimadura térmica em membro inferior direito há cerca de 25 anos, que evoluiu tardiamente com o aparecimento de lesão eritematosa, puntiforme e pruriginosa, tornando-se ulcerada e, posteriormente, úlcero-vegetante, com aumento progressivo e sem cicatrização, associada a dor e episódios de sangramento por traumas. Realizada biópsia incisional, o histopatológico confirmou tratar-se de carcinoma epidermoide bem diferenciado, desenvolvido em tecido cicatricial antigo. Foi realizada ressecção ampla da lesão, com enxertia local, sendo ainda necessária a realização de desbridamento no pós-operatório devido à necrose da enxertia. Conclusões: As lesões cicatriciais ou ulceradas crônicas que sofrem modificações no seu aspecto clínico evolutivo devem ser avaliadas como potencialmente carcinomatosas e as ulcerações com tendência à cronificação devem ser prontamente tratadas, com o emprego de enxerto, retalho ou até mesmo amputação se necessário. As áreas cicatriciais precisam sempre ser protegidas e deve-se sempre considerar o risco potencial de malignidade associada com úlceras venosas crônicas nos membros inferiores, realizando biópsias repetidas para descartar a possibilidade de transformação maligna. O paciente em questão necessitou de ressecção ampla da lesão, com enxertia local, a qual evoluiu com necrose no pós-operatório, sendo realizado desbridamento e curativos diários até que apresentasse recuperação e, posteriormente, cicatrização por segunda intenção.(AU)

Objective: A literature narrative review and description of a Marjolin ulcer case conducted at the Luiz Gioseffi Jannuzzi School Hospital, emphasizing the conduct and evolution from the literature and adopted in the case discussed. Case Report: 52 year old male, with a history of thermal burn in the lower right limb for about 25 years, who developed late with the onset of an erythematous, punctiform and pruritic lesion, becoming ulcerated and subsequently ulcer-creasing, progressive increase without healing, associated with pain and bleeding episodes due to trauma. An incisional biopsy was performed; the histopathological examination confirmed that it was a well differentiated squamous cell carcinoma, developed in old scar tissue. A wide resection of the lesion with local graft was performed, and postoperative debridement was still necessary due to the infectious complication. Conclusions: Scarring injuries or ulcerated chronic suffering changes in its evolving clinical aspect should be evaluated as potentially carcinomatous and ulcerations with a tendency to chronicity should be promptly treated with the use of graft, flap or even amputation if required. Scarring areas should be protected and should always consider the potential risk of malignancy associated with chronic venous ulcers of the lower limbs, and repeated biopsies should be performed to rule out the possibility of malignant transformation. The patient in question required extensive resection of the lesion with local graft, which evolved with postoperative necrosis, and debridement and daily dressings were performed until recovery and later, it heals by second intention. (AU)

Objetivo: Revisión narrativa de la literatura e informe de cso clínico de úlcera de Marjolin atendida en el Hospital Escuela Luiz Gioseffi Jannuzzi, haciendo hincapié en la gestión y la evolución de la literatura y cuidados adoptados en el caso discutido. Caso clínico: Hombre de 52 años, con historia de quemadura térmica en la extremidad inferior derecha de unos 25 años, que se desarrolló más tarde con la aparición de lesiones eritematosas, putiforme y pririginosa, convirtiéndose en úlcera y posteriormente ulcerada-vegetante, aumentando de forma progresiva y sin dejar cicatrices asociadas con el dolor y episodios de sangramiento por trauma. Se realiza biopsia incisional histopatología confirmó que este es el carcinoma de células escamosas bien diferenciado desarrollado en el tejido de la cicatriz antigua. Se realizó una resección amplia con lesión sitio de injerto, siendo necesario para llevar a cabo el desbridamiento postoperatorio debido a necrosis. Conclusiones: Cicatrización de heridas crónicas o cambios sufridos ulceradas en su aspecto clínico evoluciona deben ser evaluados como potencialmente carcinomatosa y ulceraciones con tendencia a la cronicidad se debe tratar oportunamente con el uso de injerto, aleta o incluso la amputación si necesario. Áreas de cicatrización siempre deben ser protegidos. El paciente en cuestión requiere una resección extensa del sitio de la lesión con el injerto, que se desarrolló con necrosis después de la operación, que se ha llevado a cabo desbridamiento y curativos diarios para que la recuperación y más tarde, la cicatrización por segunda intención.(AU)