Kummel's disease

Kummel's disease is a crush fracture of a vertebral body caused by a minor trauma, with the most accepted etiology being avascular necrosis. It is more frequent in individuals with risk factors such as osteoporosis or prolonged treatment with corticosteroids. Initially, it usually has normal radiological tests and an asymptomatic period, followed by a progressive onset of pain along with probable kyphosis and a sign of void or fluid abscess on radiological tests, which may create nerve/spinal involvement. The case is presented of a 76-year-old man, who was admitted to this center for the differential diagnosis of a single vertebral lesion. After imaging tests and biopsy, the definitive diagnosis of Kummel's disease was reached. The confirmatory diagnosis was reached by vertebral biopsy, but given its invasive nature, imaging techniques can play a significant role. As regards metabolic imaging tests, bone scintigraphy has shown to be one of the most sensitive tools to detect ischemia in earlier stages or to determine if it affects other locations. The whole body scan with diphosphonates shows an increase in activity in relation to bone remodeling activity in this condition. The 3-phase study makes it possible to differentiate whether it is an acute/subacute or chronic process, and can influence the therapeutic decision. Knowledge of this disease is important to make a differential diagnosis with tumour or infectious pathology, with emphasis on performing imaging tests in the event of persistent pain with a normal initial plaque.

La enfermedad de Kummel es una fractura-aplastamiento de un cuerpo vertebral precedida por un traumatismo menor, cuya etiología más aceptada es la necrosis avascular. Es más frecuente en individuos con factores de riesgo como osteoporosis o tratamiento prolongado con corticoides. Inicialmente, suele presentar pruebas radiológicas normales y un periodo asintomático, con aparición progresiva del dolor junto a probable cifosis y signo del vacío o absceso líquido en las pruebas radiológicas, pudiendo llegar a crear compromiso nervioso/medular. Presentamos el caso de un varón de 76 arios que ingresa en nuestro centro para el diagnóstico diferencial de una lesión única vertebral; tras la realización de las pruebas de imagen y biopsia se llega al diagnóstico definitivo de enfermedad de Kummel. El diagnóstico de confirmación de esta enfermedad se alcanza mediante la biopsia vertebral, pero dada su naturaleza invasiva, las técnicas de imagen toman un papel relevante. En relación con las pruebas de imagen metabólicas, la gammagrafía ósea ha demostrado ser una de las herramientas más sensibles para detectar isquemia en fases más tempranas o para conocer si afecta a otras localizaciones. El rastreo corporal de cuerpo completo con difosfonatos muestra un aumento de actividad en relación con la actividad ósea remodelativa en este cuadro. El estudio de tres fases permite diferenciar si se trata de un proceso agudo/subagudo o crónico, lo que influye en la decisión terapéutica. Es importante el conocimiento de esta enfermedad para realizar diagnóstico diferencial con patología tumoral o infecciosa e insistir en la realización de pruebas de imagen ante la persistencia del dolor con una placa inicial normal.

Implications of the Harmonization of [18F]FDG-PET/CT Imaging for Response Assessment of Treatment in Radiotherapy Planning.

The purpose of this work is to present useful recommendations for the use of [18F]FDG-PET/CT imaging in radiotherapy planning and monitoring under different versions of EARL accreditation for harmonization of PET devices. A proof-of-concept experiment designed on an anthropomorphic phantom was carried out to establish the most suitable interpolation methods of the PET images in the different steps of the planning procedure. Based on PET/CT images obtained by using these optimal interpolations for the old EARL accreditation (EARL1) and for the new one (EARL2), the treatment plannings of representative actual clinical cases were calculated, and the clinical implications of the resulting differences were analyzed. As expected, EARL2 provided smaller volumes with higher resolution than EARL1. The increase in the size of the reconstructed volumes with EARL1 accreditation caused high doses in the organs at risk and in the regions adjacent to the target volumes. EARL2 accreditation allowed an improvement in the accuracy of the PET imaging precision, allowing more personalized radiotherapy. This work provides recommendations for those centers that intend to benefit from the new accreditation, EARL2, and can help build confidence of those that must continue working under the EARL1 accreditation.

Central nervous system involvement in adult-onset relapsing hemophagocytic lymphohistiocytosis responsive to maintenance treatment with anakinra.

A 43 year-old male presented with a relapsing and progressive systemic inflammatory disorder with central nervous system (CNS) involvement. After a two years follow up, he was diagnosed with hemophagocytic lymphohistiocytosis (HLH), based on clinical, laboratory and radiological findings. Treatment was started with anakinra, a recombinant humanised interleukin-1 (IL-1) receptor antagonist. Clinical response was good. Laboratory and radiological findings showed no disease activity throughout a five years follow-up period. Several immunosuppressive agents have been used in HLH without any good outcomes. This is the first case report of HLH with CNS involvement responsive to chronic treatment with anakinra.

Thyroid Metastasis From Cutaneous Melanoma on an 18F-FDG PET/CT Study.

The thyroid gland is an uncommon location for metastasis. We report a 59-year-old woman with a history of cutaneous malignant melanoma. A unique hypermetabolic mass on the left thyroid lobe was identified by control F-FDG PET/CT scan, leading to dysphagia and stridor clinic. Total thyroidectomy and lymphadenectomy were performed with histopathological results concordant with metastasis from melanoma. Despite its rarity, finding focal thyroid lesions in patients with an oncological history should alert us, recommending that its metastatic etiology be ruled out.

Pneumonitis Related to Melanoma Immunotherapy.

Several regimens of immunotherapy have recently proven successful for multiple cancers, due to increased survival and quality of life. Rarely, immunotherapy with anti-programmed cell death protein 1 and programmed death-ligand 1 antibodies across cancer may cause immune-related pulmonary toxicity, with a low overall incidence, being particularly low among patients with melanoma and highest among individuals with lung cancer. In this vein, pulmonary toxicity is staged at 4 degrees according to the severity of the clinic and radiological findings, and its management is based on suppression of immunotherapy and administration of glucocorticoids. We report a case of pulmonary toxicity related to melanoma immunotherapy observed by F-FDG PET/CT.

Accurate, robust and harmonized implementation of morpho-functional imaging in treatment planning for personalized radiotherapy.

In this work we present a methodology able to use harmonized PET/CT imaging in dose painting by number (DPBN) approach by means of a robust and accurate treatment planning system. Image processing and treatment planning were performed by using a Matlab-based platform, called CARMEN, in which a full Monte Carlo simulation is included. Linear programming formulation was developed for a voxel-by-voxel robust optimization and a specific direct aperture optimization was designed for an efficient adaptive radiotherapy implementation. DPBN approach with our methodology was tested to reduce the uncertainties associated with both, the absolute value and the relative value of the information in the functional image. For the same H&N case, a single robust treatment was planned for dose prescription maps corresponding to standardized uptake value distributions from two different image reconstruction protocols: One to fulfill EARL accreditation for harmonization of [18F]FDG PET/CT image, and the other one to use the highest available spatial resolution. Also, a robust treatment was planned to fulfill dose prescription maps corresponding to both approaches, the dose painting by contour based on volumes and our voxel-by-voxel DPBN. Adaptive planning was also carried out to check the suitability of our proposal. Different plans showed robustness to cover a range of scenarios for implementation of harmonizing strategies by using the highest available resolution. Also, robustness associated to discretization level of dose prescription according to the use of contours or numbers was achieved. All plans showed excellent quality index histogram and quality factors below 2%. Efficient solution for adaptive radiotherapy based directly on changes in functional image was obtained. We proved that by using voxel-by-voxel DPBN approach it is possible to overcome typical drawbacks linked to PET/CT images, providing to the clinical specialist confidence enough for routinely implementation of functional imaging for personalized radiotherapy.

Análisis de fase en estudios Gated-SPECT como predictor de mortalidad en pacientes con enfermedad coronaria y función ventricular izquierda deprimida / Phase analysis in Gated-SPECT studies as a predictor of mortality in patients with coronary diseases and impaired left ventricular function

Resumen Antecedentes: La enfermedad coronaria es una de las principales causas de morbimortalidad en los países occidentales. En etapas avanzadas de la enfermedad, los procesos de remodelación miocárdica pueden conducir a insuficiencia cardíaca progresiva y disfunción ventricular izquierda. El análisis de fase de los estudios de perfusión miocárdica Gated-SPECT muestra parámetros que han sido caracterizados como marcadores válidos de asincronía ventricular. Objetivo: Evaluar los parámetros del análisis de fase en Gated-SPECT como predictores independientes de mortalidad en pacientes con enfermedad coronaria avanzada e insuficiencia ventricular izquierda. Materiales y método: Estudio retrospectivo de cohortes históricas de 185 pacientes consecutivos (140 hombres; edad media=67,6±12,7 años) a los que, entre enero de 2009 y marzo de 2011, se les hizo estudio isotópico de perfusión miocárdica con estimulación farmacológica con resultado positivo para isquemia/necrosis con FEVI ≤ 55%. Adicionalmente, se les realizó seguimiento medio de 32,4±10,5 meses registrándose la aparición de eventos cardíacos mayores (infarto agudo de miocardio no mortal, ingreso hospitalario y revascularización coronaria tardía) y mortalidad total. Resultados: Durante el seguimiento se registraron eventos mayores en 51 pacientes así como 28 fallecimientos, de los cuales, 82,1% mostró valores alterados de los parámetros de fase: media=141,1(±17,6(; desviación estándar=15,8(±10,1(; ancho de banda=59,1(±36( y FEVI=42,4%±10,8%. El análisis de Cox mostró al ancho de banda como un predictor independiente de muerte, disminuyendo significativamente la supervivencia y aumentando el riesgo de muerte (hazard ratio=2,68; p<0,05). Conclusiones: El ancho de banda en el análisis de fase se comporta como un predictor independiente de muerte en pacientes con miocardiopatía conocida y FEVI deprimida.

Abstract Background: Coronary disease is one of the main causes of morbidity and mortality in western countries. In the advanced stages of the disease the myocardial remodelling processes can lead to progressive heart failure and left ventricular impairment. The phase analysis of Gated-SPECT studies of myocardial perfusion show parameters that have been characterised as valid marker of ventricular asynchrony. Objective: To evaluate the phase analysis parameters in Gated SPECT as independent predictors of mortality in patients with advanced coronary disease and left ventricular failure. Materials and method: A retrospective historic cohort study was conducted on 185 consecutive patients (140 males; mean age = 67.6±12.7 years) on whom, between January 2009 and March 2011, an isotope myocardial perfusion study was carried out with pharmacologic stimulation and with a positive result for ischaemia / necrosis, and with a LVEF ≤ 55%. A mean follow-up of 32.4 ±10.5 months was also performed, recording the appearance of major cardiac events (non-fatal acute myocardial infarctions, hospital admission, delayed coronary revascularisation, and total mortality. Results: Major events were recorded in 51 patients during follow-up. There were also 28 deaths, of which 82.1% showed abnormal values of the phase parameters: media=141.1(±17.6(; standard deviation=15.8(±10.1(; bandwidth=59.1(±36(, and LVEF = 42.4%±10.8%. The Cox analysis showed the bandwidth as an independent predictor of death, significantly reducing the survival and increasing the risk of death (hazard ratio=2.68; P<.05). Conclusions: The bandwidth in the phase analysis behaves as an independent predictive factor in patients with known myocardial disease and an impaired LVEF.

Virchow Node From Prostate Carcinoma by 18F-Choline PET/CT.

F-choline PET/CT is increasingly being used during the follow-up of prostate cancer and is bringing us valuable information for the delineation of local and distant nodal recurrence in patients with hormone-resistant poorly differentiated cell types. Lymphatic spreading usually involves pelvic and retroperitoneal levels, being unusual at supraclavicular levels. We report a 75-year-old man with unsuspected involvement of Virchow node from prostate cancer observed using F-choline PET/CT.

Intrathoracic stomach mimicking bone metastasis from thyroid cancer in whole-body iodine-131 scan diagnosed by SPECT/CT

SUMMARY The whole-body iodine-131 scintigraphy is an imaging technique in monitoring patients with a history of thyroid cancer. Although the rate of false positives is negligible, it is not nonexistent. We report the case of an intervened and treated patient for thyroid cancer with good clinical and biochemical response. Scintigraphic findings were consistent with unsuspected bone metastasis. Fused SPECT/CT data allowed accurate diagnosis of giant diaphragmatic hernia associated with intrathoracic stomach, a very rare pathology that can lead to false positive results.

Esophageal Cancer Diagnosed by Thyroid Scintigraphy.

We report a 34-year-old man referred because of increasing dysphagia secondary to goiter. Thyroid scintigraphy and SPECT/CT images helped to recognize an unsuspected esophageal dilation due to a poorly differentiated adenocarcinoma arising at the lower end of the esophagus. Further examinations are mandatory when abnormal activities are observed during thyroid scintigraphy.

Intrathoracic stomach mimicking bone metastasis from thyroid cancer in whole-body iodine-131 scan diagnosed by SPECT/CT.

The whole-body iodine-131 scintigraphy is an imaging technique in monitoring patients with a history of thyroid cancer. Although the rate of false positives is negligible, it is not nonexistent. We report the case of an intervened and treated patient for thyroid cancer with good clinical and biochemical response. Scintigraphic findings were consistent with unsuspected bone metastasis. Fused SPECT/CT data allowed accurate diagnosis of giant diaphragmatic hernia associated with intrathoracic stomach, a very rare pathology that can lead to false positive results.